®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®®<*®®®(S 


Presented  by 
J.  A.  McNaughton 


COLLEGE   OF   OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •   LOS  ANGELES,  CALIFORNIA 


TRANSVERSE  COLON 


LOOPOF  SMALL.. 
INTESTINE 


CECUM 

RECTUM 

VERMIFORM     i 
APPENDIX 


"GREAT  OMENTUM 


LOOP  OF  SMALL 
INTESTINE 


DEEP  EPIGASTRIC  A 


'  ROUND  LIGAMENT 
BLADDER  distended 
FALLOPIAN  TUBES 
EXTERNAL  ILIAC  A  behind  peritoneum          URACHUS 
APPENDICULOOVARIAN  LIGAMENT 


A 
NEW 

CLINICAL  SURGERY 


BY 

ALBERT  J.  bcHSNER,  B.  S.,  M.  D.,  F.  R.  M.  S.,  LL.D., 

Professor  of  Clinical  Surgery,  Medical  Department,  University  of  Illinois; 
Surgeon-in-Chief  of  Augustana  and  St.  Mary's  Hospitals,  etc.,  Chicago. 

AND 

NELSON  M.  PERCY,  M.  D., 

Instructor  in    Surgery,  Medical  Department  University   of    Illinois;    Attending 
Surgeon,  St.  Mary's  Hospital ;  Junior  Surgeon,  Augustana  Hospital,  etc.,  Chicago. 


THIRD    EDITION-REVISED    AND    ENLARGED 


COMPLETE  IN  ONE  VOLUME 


FULLY  ILLUSTRATED 


CLEVELAND  PRESS 

CHICAGO 

1911 


0 


Copyright 

by  the 

CLEVELAND  PRESS 
1910 


PREFACE  TO  THE  THIRD  EDITION. 

For  some  time  there  has  been  a  demand  for  a  third  edition  of  this 
work  but  until  the  present  it  has  been  impossible  for  us  to  give  the  neces- 
sary attention  to  make  the  careful  revision  which  seemed  indicated.  During 
the  interval  since  the  publication  of  the  second  edition  we  have  collected 
material  constantly  for  this  new  edition.  We  have  also  had  ample  oppor- 
tunity to  test  many  of  the  newer  methods  and  to  confirm  many  of  the  old 
ones  as  we  have  kept  careful  records  of  more  than  fifteen  thousand  opera- 
tions performed  by  us  in  this  period. 

Our  methods  have  been  adopted  from  many  surgeons  and  adapted  to 
our  conditions.  In  many  instances  these  surgeons  have  kindly  furnished 
personal  information  and  illustrations  for  which  we  wish  to  express  sincere 
gratitude,  as  also  for  the  inspiration  and  encouragement  experienced  through 
contact  with  these  enthusiastic  and  tireless  workers  in  the  field  of  surgery. 

A.  J.  O. " 
N.  M.  P. 

PREFACE  TO  THE  SECOND  EDITION. 

In  the  preparation  of  the  second  edition  the  same  general  plan  has 
been  followed  that  was  introduced  in  the  first. 

With  increased  experience  in  the  use  of  operations  which  had  not 
been  fully  tried,  it  has  been  possible  to  make  some  portions  of  the  text 
more  complete. 

The  additional  material  has,  however,  all  been  substantiated  by  my 
own  clinical  experience  and  can  be  depended  upon  in  the  same  manner 
as  the  portion  of  the  book  which  appeared  originally. 

In  the  chapter  on  stomach  surgery  an  article  by  Dr.  W.  J.  Mayo 
has  been  introduced  in  full  because  this  covers  the  subject  so  perfectly 
that  it  would  be  impossible  to  improve  upon  it.  I  am  again  greatly  in- 
debted to  this  author  for  many  valuable  suggestions  as  well  as  for  a 
number  of  most  excellent  original"  plates. 

The  text  has  been  increased  by  about  sixty  pages,  and  the  number 
of  plates  has  been  increased  by  nearly  fifty  per  cent. 

The  views  expressed  concerning  the  treatment  of  certain  forms  of 
appendicitis,  which  differed  materially  from  the  generally  accepted  plan 
at  the  time  of  publication  of  the  first  edition,  has  been  tried  by  hundreds 
of  surgeons  who  have  been  able  to  follow  the  method  carefully  as  de- 
scribed in  this  volume.  Many  of  these  have  kindly  informed  me  of  the 
success  they  have  obtained  in  this  direction. 

My  own  experience  in  the  treatment  of  more  than  one  thousand  cases 
of  appendicitis  during  the  past  three  years  has  further  confirmed  the 
correctness  of  these  views. 

I  wish  to  express  my  thanks  to  the  many  surgeons  who  have  shown 
their  appreciation  of  my  efforts  in  the  production  of  the  first  edition. 

A.  T-  O. 


PREFACE  TO  THE  FIRST  EDITION. 

Many  practitioners  who  have  honored  the  author  by  visiting  his  clinic 
have  requested  that  a  work  on  Clinical  Surgery  be  written  by  him,  giving 
as  nearly  as  possible  the  methods  adopted  in  actual  practice.  This  request 
has  been  met  by  the  statement  that  the  author  lays  no  claim  to  the  invention 
of  a  single  new  operation,  nor  has  he  produced  a  new  or  modified  instru- 
ment, but  has  contented  himself  with  applying-  to  his  surgical  work  what 
seemed  best  in  the  practice  of  the  surgeons  of  the  past  and  present,  many 
times  without  knowing  by  whom  the  various  methods  were  modified  before 
they  were  accepted  and  used  by  him. 

This  book  is  therefore  offered  for  what  it  is  worth  under  the  limitations 
mentioned,  the  author  being  conscious  of  a  certain  incompleteness  because 
of  adhering  closely  to  the  intention  of  producing  a  work  reflecting  almost 
entirely  the  methods  which  have  been  thoroughly  tried  in  his  own  practice. 

In  recommending  certain  steps  the  author  does  not  desire  to  impress 
the  fact  that  the  method  chosen  or  advised  is  the  best,  or  the  only  good 
one,  but  rather  that  it  stands  as  a  means  he  has  thoroughly  tried  and  which 
can  be  reasonably  relied  upon.  Whenever  there  is  any  doubt  upon  this 
point  it  is  expressly  so  stated  in  the  text. 

There  are  necessarily  some  branches  of  clinical  surgery  in  which  the 
author's  experience  is  limited,  and  it  has  seemed  best  to  indicate  this  in 
the  text  in  discussing  the  special  subjects  thus  impaired. 

Certain  operations  can  obviously  have  no  place  in  this  volume,  because 
they  have  been  described  in  a  given  way  by  many  writers  for  years,  and 
would  simply  consume  space  for  reiteration  without  increasing  the  value 
of  the  work.  I  refer  especially  to  the  typical  ligations,  amputations  and 
the  resections  of  joints. 

A  portion  of  this  work  deals  with  clinical  cases  taken  from  hospital 
records  and  discussed  as  one  discusses  such  cases  in  practice.  This  has 
been  done  for  the  purpose  of  bringing  the  actual  clinical  conditions  before 
the  mind  of  the  reader.  It  did  not  seem  wise  to  carry  this  plan  through 
the  subjects  in  which  it  was  possible  to  bring  out  the  salient  points  in  more 
concentrated  manner.  In  order  to  impress  the  reader  with  the  cardinal 
facts  upon  which  success  in  the  treatment  of  -various  conditions  depends, 
many  unimportant  and  useless  matters  have  been  intentionally  omitted. 
This  undoubtedly  reduces  the  scientific  merit  of  the  book,  but  it  has 
appeared  to  the  author  to  increase  its  practical  value. 

No  reference  is  made  to  authors  whose  methods  are  described,  because 
most  of  the  procedures  set  forth  were  not  used  in  their  original  form, 
having  been  repeatedly  modified,  usually  by  a  number  of  operators.  In 
order  to  give  each  one  the  due  amount  of  credit  deserved  the  work  would 
have  grown  far  beyond  the  designed  limits.  An  exception  is  made  in  those 
cases  in  which  the  original  drawings  of  writers  are  employed.  The  author 
is  indebted  to  all  of  his  friends  in  the  surgical  profession  whose  methods 
he  has  adopted,  and  hopes  that  where  they  find  familiar  details  they  will 
appreciate  the  gratitude  he  bears  toward  them  for  having  markedly  assisted 
in  the  improvement  of  his  technique. 


PREFACE     TO     THE     FIRST     EDITION  9 

All  drawings  herein  are  original,  having  been  made  by  Miss  Alice  L. 
Cleaveland  for  this  volume  from  immediate  operations,  with  the  exception 
of  a  few  which  were  taken  from  original  publications  of  other  authors ;  the 
latter  are  especially  designated  in  their  accompanying  text. 

The  author  is  particularly  indebted  to  his  friend,  Dr.  W.  J.  Mayo,  for 
many  valuable  suggestions,  and  to  his  brother,  Dr.  E.  H.  Ochsner,  and  his 
chief  assistant,  Dr.  Nelson  M.  Percy,  for  relieving  him  of  many  burdens 
incident  to  the  production  of  a  book. 

Finally,  it  should  be  said  that  this  work  is  not  written  for  the  great 
surgeon,  or  the  teacher  of  surgery,  whose  methods  are  as  well  tried  as 
those  contained  in  this  volume,  and  undoubtedly  quite  as  useful,  but  rather 
for  the  man  who  is  compelled,  by  virtue  of  the  circumstances  surrounding 
him,  to  do  surgery,  and  who  wishes  to  know  what  the  author  would  do 
in  a  similar  case  to  the  one  he  happens  to  have  under  treatment  at  any 
given  time.  He  may  be  familiar  with  many  methods,  but  at  the  same  time 
may  wish  to  know  which  one  has  seemed  most  satisfactory  to  the  author. 

A.  J.  O. 


LIST  OF  ILLUSTRATIONS 


PLATES 


PAGE 


The  abdominal   viscera ( Frontispiece) 

I.     Temporary  resection  of  the  skull 117 

II.     Cleft  palate  operation 129 

Til.     Excision  of  the  tongue 145 

Ilia.     Thyroidectomy    150 

IV.     Amputation  of  the  breast 199 

V.     Amputation  of  the  breast 203 

VI.     Amputation  of  the  breast 203 

VII.     Amputation  of  the  breast 205 

VIII.     Amputation  of  the  breast 207 

IX.     Amputation  of  the  breast 209 

X.     Amputation  of  the  breast 209 

XI.     Amputation  of  the  breast 211 

XII.     Amputation  of  the  breast 213 

XIII.  Location  of  abdominal  incisions 225 

XIV.  Location   of  abdominal   incisions 229 

XV.     Excision  of  the  appendix 233 

XVI.      Cecurn  with   appendix   removed 237 

XVII.     Excision  of  the  appendix 239 

XVIII.     Excision  of  the  appendix 241 

XIX.     McBurney's  incision 247 

XX.     Abdominal  wound 253 

XXI.      Abdominal  wound 257 

XXII.     Closure  of  the  abdominal  wound 259 

XXIII.  Constricted    appendix 281 

XXIV.  Adherent   appendix 287 

XXV.      Syringe  and  catheter  for  rectal   feeding 289 

XXVI.     Adherent    appendix 291 

XXVII.     Abdominal    incision 293 

XXVIII.     Abdominal    incision 295 

XXIX.     Abdominal    incision 297 

XXX.      Closure  of   McBurney  incision 299 

XXXI.      Means  for  preventing  suture  marks 303 

XXXII.     Intestinal    anastomosis 331 

XXXIII.  Lateral  intestinal  anastomosis 335 

XXXIV.  Intestinal    anastomosis 341 

XXXV.     Connell  method  of  suturing 345 

XXXVI.     Connell  method  of  suturing 347 

XXXVII.     End-to-end  anastomosis  of  colon 351 

XXXVIII.      End-to-end  anastomosis  of  colon 353 

XXX IX.     Inguinal    colostomy 357 

XL.      Excision  of  upper  portion  of  the  rectum 3lil 

XLT.      Excision  of  upper  portion  of  the  rectum 3ti5 

XLI  I.      Anatomy   of   inguinal   region 377 

XLIII.     Ferguson's    herniotomv 379 


12 


LIST     OF     ILLUSTRATIONS 


XLIV.  Ferguson's  operation  for  inguinal  hernia 383 

XLV.  Inguinal  hernia 385 

XLVI.  Inguinal  hernia 389 

XLVII.  Inguinal  hernia 393 

XLVIII.  Inguinal  hernia 395 

XLIX.  Bassini's  operation  for  inguinal  hernia 397 

L.  Typical  appearance  of  femoral  hernia 401 

LI.  Anatomy  of  the  femoral  region 403 

LI1.  Femoral    hernia 407 

LIII.  Umbilical    hernia 411 

LIV.  Umbilical    hernia 415 

LV.  Umbilical    hernia 417 

LVI.  McBurney's  incision 421 

LVII.  Closure  of  abdominal  wound 425 

LVIII.  Cross  section  of  abdominal  wall 429 

LIX.  Cross  section  of  abdominal  wall 431 

LX.  Cross  section  of  abdominal  wall 433 

LXI.  Closure  of  abdominal  wound 437 

LXII.  Closure  of  abdominal  wound 439 

LXIII.  Splenectomy  461 

LXIV.  Clamp  and  cautery  operation  for  hemorrhoids 471 

LXV.  Elastic  dilating  bougie  (esophageal) 489 

LXVI.  Gastrostomy  493 

LXVII.  Gastrostomy 495 

LXVIII.  Gastrostomy 497 

LXIX.  Gastrostomy  499 

LXX.  Gastrostomy  501 

LXXI.  Plummet's  whalebone  staff 525 

LXXII.  Mayo-Moynihan  gastro-enterostomy 537 

LXXI1I.  Mayo-Moynihan  gastro-enterostomy 539 

LXXIV.  Mayo-Moynihan  gastro-enterostomy 543 

LXXV.  Mayo-Moynihan  gastro-enterostomy 545 

LXX VI.  Mayo-Moynihan  gastro-enterostomy 547 

LXXVII.  Mayo-Moynihan  gastro-enterostomy 549 

LXXVIII.  Mayo-Moynihan  gastro-enterostomy 551 

LXXIX.  Mayo-Moynihan  gastro-enterostomy 553 

LXXX.  Enterostomy    559 

LXXXI.  Enterostomy    561 

LXXXII.  Enterostomy    563 

LXXXIIT.  Enterostomy    565 

LXXXIV.  Enterostomy    567 

LXXXV.  Gastro-enterostomy    571 

LXXXVT.  Gastro-enterostomy   573 

LXXXVIT.  Gastro-enterostomy   575 

LXXXVIIT.  Distribution  of  stomach  lymph  nodes 581 

LXXXIX.  Carcinoma  of  the  pylorus 585 

XC.  Carcinoma  of  the  pylorus 587 

XCt.  Pylorectomy 589 

XC1 1.  Pylorectomy  591 

XCII 1.  Pylorectomy 593 

XCVI.  Gastroptosis   597 

XCVII.  Some  instruments  used  in  trail  bladder  surgerv 613 


LIST     OF1     ILLUSTRATIONS 


XCVIII.     Cholecystotomy  617 

XCIX.     Retention    tube 619 

C.     Removal  of  stone  from  common  duct 621 

CI.     Excision  of  the  gall  bladder 623 

CII.     Excision  of  the  gall  bladder 625 

CIII.     Excision  of  the  gall  bladder 627 

CIV.     Excision  of  the  gall  bladder 629 

CV.     Mayo   Robson's  position 633 

CVI.     Circular  muscle  fibres  of  the  duodenum 637 

CVII.     Resection  of  liver 643 

CVIII.     Resection  of  liver 64"; 

CIX.     Atrophy  of  the  kidney (Jo.") 

CX.     Hydronephrosis    661 

CXI.     Hydronephrosis    663 

CXII.      Plastic  operation  on  the  kidney 667 

CXIII.      Plastic  operation  on  the  kidney 669 

CXIV.     Nephrorrhaphy   675 

CXV.     Nephrorrhaphy   679 

CXVI.     Van  Hook's  anastomosis  of  the  ureter 683 

CXVII.     Carcinoma  of  the  penis  and  scrotum 689 

CXVIII.     Excision  of  the  male  genitalia 691 

CXIX.     Excision  of  the  male  genitalia 693 

CXX.     Excision  of  the  male  genitalia 695 

CXXI.     Hypospadias  operation 699 

CXXII.     Hypospadias  operation 701 

CXXI1I.     C.  H.  Mayo  hypospadias  operation 703 

CXXI V.     C.  H.  Mayo  hypospadias  operation 705 

CXXV.     C.  H.  Mayo  hypospadias  operation 707 

CXXVI.     C.  H.  Mayo  hypospadias  operation 709 

CXXVII.     C.  H.  Mayo  hypospadias  operation 711 

CXXVIII.     C.  H.  Mayo  hypospadias  operation 713 

CXXIX.     C.  H.  Mayo  hypospadias  operation 715 

CXXX.     C.  H.  Mayo  hypospadias  operation 717 

CXXXI.     Varicocele  operation 723 

CXXXII.     Encysted   hydrocele I'll 

CXXXI1I.     Prostatectomy    743 

CXXXIV.     Abdominal   incision 757 

CXXXV.     Closure  of  abdominal  incision 750 

CXXXVI.     Abdominal  hysterectomy 765 

CXXXVII.     Abdominal  hysterectomy 767 

CXXXVIII.     Abdominal  hysterectomy 769 

CXXXIX.     Vaginal  hysterectomy 779 

CXL.     Vaginal  hysterectomy 781 

CXLI.     Vaginal  hysterectomy 783 

CXLII.     Vaginal  hysterectomy 785 

CXLIII.     Uterine  carcinoma 789 

CXLIV.     Excision  of  elongated  cervix 795 

CXLV.     Excision  of  elongated  cervix 797 

CXLVI.     Closure  of  wound  of  cervix 799 

CXLVII.     Amputation  of  cervix 801 

CXLVIII.     Amputation   of  cervix 803 

CXLIX.     Amputation   of  cervix 805 


14  LIST     OF     ILLUSTRATIONS 

CL.  Perineorrhaphy   811 

CLI.  Excision  of  female  urethra 813 

CLII.  Radiograpli  of  ununited  fracture 829 

CLIII.  Radiograph  of  ununited  fracture 831 

CLIV.  Moist   antiseptic    dressing 839 

CLV.  Nerve    suture 849 

CLVI.  Operation  for  lengthening  tendons 853 

CLVII.  Excision  of  the  ankle 857 

CLVIII.  Ingrown  toe  nail 875 


FIGS.  PAGE 

1.  Red  blood  cell  count 35 

2.  Leucocyte   count 37 

3.  Anterior  incisional  lines 77 

4.  Anterior    abdominal   incisional   lines 81 

5.  Posterior  incisional  lines 85 

C.     De  Vilbiss  forceps 101 

7.  De  Vilbiss  forceps 101 

8.  De  Vilbiss  forceps 101 

9.  Areas  of  cerebral  localization 109 

10.  Areas  of  cerebral  localization 109 

1 1 .  Areas  for  osteoplastic  operations 113 

12.  Tracheotomy    175 

13.  Tracheotomy   and   laryngectomy 175 

14.  Lateral   intestinal   anastomosis 338 

15.  Murphy    button 339 

16.  Carcinoma  of  the  cecum 309 

17.  Anatomy  of    femoral   region 409 

18.  Ventral  hernia 423 

19.  Fistulse  in  ano 476 

20.  Dilatation  of  stricture  of  esophagus 513 

21.  Dilatation  of  stricture  of  esophagus 515 

22.  Dilatation  of  stricture  of  esophagus 517 

23.  Dilatation  of  stricture  of  esophagus 519 

24.  Harris'   segregator 051 

25.  Willys  Andrews'  hydrocele  operation 729 

26.  Mayo's  operation   for  bunion 873 

27.  Mayo's  operation   for  bunion 873 

28.  Mayo's  operation   for  bunion 873 

29.  Hospital  location   plan 881 

30.  Hospital  location  plan 881 

31.  Block  plan  of  hospital 883 

32.  Hospital  plan 885 

33.  An  undesirable  hospital  plan 887 

34.  Hospital  plan 891 

35.  Hospital  plan 893 

36.  Hospital  plan ' 897 

37.  Hospital  plan 899 

38.  Hospital  plan 903 


PART    I. 


GENERAL     SURGICAL      CONSIDERATIONS. 

EXAMINATION   OF  THE  PATIENT 

The  benefits  of  clinical  surgery  cannot  be  realized  to  the  fullest  extent 
without  considering  the  patient  himself,  aside  from  the  disease  for  the 
cure  of  which  he  seeks  surgical  treatment. 

Much  of  the  surgeon's  success  depends  upon  the  value  of  his  judgment 
and  knowledge  outside  of  his  especial  line  of  work. 

Many  patients  may  live  in  relative  comfort  for  a  considerable  period 
of  time  whose  lives  may  be  cut  short  by  an  attempt  to  obtain  complete 
relief.  On  the  other  hand,  many  patients  may.  with  the  same  degree  of 
safety,  obtain  complete  relief,  rather  than  partial,  as  a  result  of  the  ex- 
cellence of  the  surgeon's  judgment. 

Clinical   Experience   of  the   Surgeon. 

To  excel  to  the  fullest  extent,  the  surgeon  requires  not  only  the 
necessary  knowledge  to  make  the  proper  diagnosis,  and  technical  skill  to 
perform  the  necessary  operation,  but  he  must  also  have  an  extensive  clinical 
experience,  which  can  fortunately  be  obtained,  in  this  country  at  least, 
in  service  as  assistant  to  those  who  possess  this  experience,  particularly 
in  the  great  number  of  excellent  hospitals  which  have  been  established  in 
most  of  the  larger  cities. 
General  Examination  of  the  Patient. 

In  order  to  be  able  to  judge  of  the  patient's  condition,  aside  from  the 
particular  ailment  from  which  he  is  suffering,  it  is  necessary  in  each  case 
to  make  a  careful  general  examination.  This  should  include  a  physical 
examination  of  the  chest,  the  abdomen,  the  nervous  system,  the  urine,  and 
at  least  an  observation  of  the  character  of  the  faeces.  In  many  cases  the 
blood  should  be  examined.  If  there  is  cough  the  sputum  should  be  exam- 
ined microscopically. 

Diagnostic  Section  of  Tumors  Condemned. 

In  making  an  examination  we  should,  however,  be  exceedingly  careful 
not  to  fall  into  the  opposite  error  of  making  a  diagnosis  without  regard  to 
the  patient.  \Ye  have  repeatedly  seen  patients  lose  their  lives  because  of  the 
fact  that  the  surgeon  felt  it  his  duty  to  make  a  positive  diagnosis.  This  is 
especially  true  of  cases  in  which  portions  of  safely  removable  tumors  were 
excised,  previous  to  their  total  removal,  for  microscopic  examination  for 
the  purpose  of  making  a  positive  diagnosis.  In  these  cases  we  have  fre- 
quently seen  metastases  appear  very  soon  after  this  apparently  unimportant 
preliminary  diagnostic  operation  was  performed,  which  were  probably  due 
to  the  excision  of  the  small  portion.  \Ye  believe  this  should  be  very  strongly 


l8  GENERAL    SURGICAL     CONSIDERATIONS 

condemned,  because  the  removal  of  a  benign  tumor  is  in  reality  a  harmless 
performance  compared  with  the  dissemination  of  a  malignant  growth. 
There  are  but  few  exceptions  to  this  rule,  chiefly  in  case  of  bone  tumors  in 
which  the  treatment  of  a  malignant  growth  would  necessitate  an  amputa- 
tion, while  a  benign  tumor  can  safely  be  removed  from  the  implicated  bone. 

Diagnostic  Palpation  of  Tumors  Condemned. 

In  connection  with  the  diagnosis  of  malignant  tumors  we  would  also 
caution,  very  emphatically,  against  applying  much  pressure  to  the  surfaces 
of  these  growths.  We  have  observed  many  cases  of  carcinoma  of  the  breast, 
for  instance,  which  had  remained  almost  stationary  for  many  months  until 
the  patient  began  to  have  it  examined.  Each  successive  examining  physician 
and  all  the  patient's  friends  had  thoroughly  massaged  the  growth  during 
repeated  examinations  and  it  seems  reasonable  to  suppose  that  in  this  way 
the  rapid  increase  in  growth,  the  involvement  of  the  lymphatic  glands, 
and  possibly  the  metastasis  in  the  liver  could  be  explained,  because  of  the 
likelihood  of  forcing  cells  from  the  primary  growth  into  the  lymph  channels. 

In  the  same  manner,  we  have  observed  that  patients  suffering  from  sep- 
tic infections  of  the  extremities  regularly  show  a  rise  in  temperature  after 
a  thorough  examination,  during  which  every  effort  was  made  to  locate 
points  of  fluctuation. 

It  seems  reasonable,  therefore,  to  condemn  what  might  be  called  diag- 
nostic massage,  at  least  in  all  patients  suffering  from  malignant  growths 
and  septic  infections. 

Exploring  Syringe  Condemned. 

The  exploring  syringe  is  an  instrument  which  is  also  responsible  for 
much  harm,  because  in  many  cases  in  which  pus  has  been  diagnosed  posi- 
tively without  this  instrument,  the  syringe,  instead  of  confirming  the  diag- 
nosis, shows  negative  results,  on  account  of  some  obstruction  in  the  lumen 
of  the  exploring  cannula  used. 

In  a  number  of  instances  we  have  seen  great  accumulations  of  gas  re- 
moved from  empyemata  and  other  abscesses  after  repeated  tests  with  the 
exploring  syringe  had  resulted  negatively.  This  is  frequently  the  case,  even 
when  a  needle  with  large  caliber  is  used.  Many  an  abscess  has  remained 
unopened  because  the  exploring  needle  was  supposed  to  afford  a  positive 
test. 

In  other  cases  extensive  and  serious  infections  have  been  caused  by 
the  use  of  the  exploring  syringe  because  the  great  pressure  under  which  the 
pus  was  confined  in  the  abscess  has  forced  it  into  the  surrounding  tissues 
or  cavities  along  the  puncture  made  by  the  exploring  needle. 

In  exploring  the  brain  for  the  location  of  an  abscess  it  is  sometimes 
necessary  to  use  an  exploring  syringe  with  a  large  cannula — it  may  also 
be  useful  in  differentiating  between  pleurisy  with  effusion  and  empyema — 
but  aside  from  this  we  believe  that  its  use  should  be  discarded. 

All  that  has  been  said  against  the  use  of  the  exploring  syringe  can  be 
said  with  much  greater  emphasis  against  an  instrument  which  has  fortu- 
nately been  almost  entirely  discarded,  namelv.  the  grooved  exploring  needle. 
This  instrument  possesses  all  of  the  bad  qualities  of  the  exploring  syringe 
to  an  exaggerated  extent,  without  having  any  of  its  good  qualities. 

If  it  seems  advisable  to  make  use  of  an  exploring  syringe  in  a  given 
case  it  should  be  armed  with  trocar  of  the  desired  size  instead  of  the  ordi- 


GENERAL     SURGICAL     CONSIDERATIONS  IQ 

nary  aspirating  needle,  as  the  former  is  much  less  likely  to  be  obstructed 
and  is  therefore  more  certain  to  give  the  desired  information. 

The  Personal  Element  of  Risk  in  Operations. 

In  considering  the  patient  in  relation  to  the  advisability  of  an  opera- 
tion, it  will  be  found  that  in  a  large  majority  of  cases  there  is  scarcely  any 
doubt  regarding  his  ability  to  bear  the  operation  itself,  barring  accidents ; 
but  this  fact  should  not  lead  us  to  take  for  granted  that  this  will  be  the 
case  in  any  individual  case  without  having  taken  pains  to  make  sure.  With 
experience  one  learns  to  place  certain  cases  in  the  class  of  good  risks  and 
others  in  the  class  of  bad  risks,  with  many  intermediate  grades ;  and  it  is 
not  an  easy  matter  to  classify  these  cases  so  that  one  who  has  not  actually 
come  in  contact  with  them  can  appreciate  their  difference  even  with  a  very 
minute  description. 

We  would  class  among  the  good  risks  patients  who  are  nearly  normal 
as  regards  all  the  organs  of  the  body,  with  the  exception  of  the  part  in- 
volved in  the  disease  for  which  the  operation  is  to  be  performed ;  if  the  dis- 
ease is  not  located  within  or  near  an  important  organ;  and  provided  that  the 
operation  is  not  to  be  done  for  the  relief  of  a  disease  due  to  an  acute  in- 
fection. If  the  operation  is  to  be  performed  for  the  relief  of  an  acute  in- 
fection, then  the  risk  will  depend  upon  the  question, — Can  the  progress  of 
this  infection  surely  be  prohibited  by  the  operation? 

It  seems  that  an  acute  infection  does  not  respect  natural  strength  or 
endurance.  We  have  here,  however,  quite  a  safe  guide  in  the  condition  of 
the  pulse.  An  operation  performed  upon  a  patient  with  a  pulse  of  over 
1 20  beats  per  minute  must  always  be  looked  upon  as  serious,  and  with  a 
pulse  still  higher  the  gravity  of  the  condition  increases  rapidly. 

If  the  operation  will  remove  the  existing  septic  material  and  at  the 
same  time  make  a  further  infection  impossible,  or  at  least  unlikely,  then  it 
must  be  looked  upon  as  being  relatively  safe. 

OLD  AGE. 

Old  Age  of  Itself  Not  a  Contraindication  to  Surgery. 

Among  the  conditions  almost  always  enumerated  as  contra-indicating 
serious  operations  is  old  age.  There  are  certain  very  good  reasons  for  this. 
A  person  who  has  lived  many  years  has  had  relatively  more  opportunity  to 
impair  his  various  organs  than  one  who  has  lived  a  shorter  time.  Moreover, 
his  tissues  are  in  themselves  old,  and  especially  his  blood  vessels  have  lost 
much  of  their  elasticity.  On  the  other  hand,  we  must  bear  in  mind  that  the 
fact  that  these  persons  have  attained  great  age  would  indicate  that  they 
were  primarily  well  made  or  that  their  normal  resources  have  been  well 
preserved. 

Asa  matter  of  experience,  we  would  state  that  in  the  absence  of  obesity, 
arterio-sclerosis,  nephritis,  marked  anemia,  or  cachexia,  due  to  the  pres- 
ence of  malignant  growths,  patients  advanced  in  years  bear  surgical  opera- 
tions well,  if  they  are  permitted  to  move  about  and  sit  up  soon  after  the 
operation.  (This  allowance  rarely  interferes  with  the  recovery  after  any 
operation,  provided  we  bear  this  in  mind  in  the  suturing  of  the  wound  and 
in  applying  the  dressings). 

Confinement  to  be  Avoided. 

To  one  whose  attention  had  not   been  directed  to  this  peculiarity  of 


2O  GENERAL    SURGICAL    CONSIDERATIONS 

patients  advanced  in  years  it  might  seem  foolhardy  to  permit  the  patient  10 
sit  up  on  the  day  following  so  serious  an  operation  as  amputation  of  the 
breast  with  removal  of  the  pectoralis  major  and  minor  muscles  and  the 
axillary  fat  and  lymph  glands,  but  experience  leads  us  to  say  that  in  opera- 
tions as  severe  even  as  this  one,  the  course  mentioned  is  strongly  to  be 
advised. 
Lowered  Resistance  from  "High"  Life. 

There  is  one  element  which  it  is  well  to  bear  in  mind  in  connection 
with  the  consideration  of  old  age  in  surgery.  Many  times  patients  not 
much  over  forty  years  of  age,  whose  lives  since  adolescence  have  been 
spent  under  conditions  of  severe  mental  tension,  so  common  among  busi- 
ness and  professional  men  at  the  present  time,  show  a  degree  of  senility  so 
far  as  their  nervous  and  vascular  systems  are  concerned,  which  indicates 
that  they  should  be  classed  with  those  who  are  in  reality  from  twenty  to 
thirty  years  older.  In  these  patients  one  encounters  a  high  degree  of  arte- 
rial tension,  an  erratic,  nervous  heart,  and  there  is  usually  a  deficiency  in 
the  excretion  of  urea.  This  condition  is  much  more  common  among  men 
than  among  women,  because  men  are  more  constantly  exposed  to  nervous 
and  mental  strain  than  women,  with  the  possible  exception  of  the  small  and 
useless  class  known  as  ''society"  women,  which  is  so  unimportant  as  not  to 
require  attention  save  to  point  the  contrast.  This  condition  of  instability  is 
undoubtedly  exaggerated  by  the  poisonous  effects  of  nicotin  and  alcohol, 
which  serve  so  well  as  temporary  stimulants  in  relieving  the  immediate  dis- 
tress of  mental  and  nervous  strain  to  which  professional  men  and  business 
men  are  exposed. 

In  these  cases  thorough  elimination  by  the  use  of  very  little  easily  di- 
gestible food,  the  taking  of  large  quantities  of  good  water,  the  gradual  re- 
duction in  the  use  of  tobacco  and  abstinence  from  alcohol  are  strongly  in- 
dicated. 

Fresh  buttermilk  seems  to  be  especially  useful  both  as  a  food  and  as  an 
eliminant  in  these  cases.  Castor  oil  given  in  two-ounce  doses  in  the  foam 
of  beer  or  ale  or  extract  of  malt  aids  greatly  in  improving  the  condition 
of  this  class  of  patients. 

These  patients  should  never  be  exposed  to  long  continued  operations, 
and  they  are  especially  bad  subjects  for  nitrous  oxide  gas  anesthesia,  be- 
cause of  its  effects  in  increasing  the  blood  pressure. 

The  use  of  continuous  proctolysis  under  low  pressure  or  by  the  drop 
method  following  operation  is  especially  valuable  in  this  class  of  cases  be- 
cause by  favoring  elimination  this  method  greatly  relieves  the  circulatory 
system. 

Many  cases  do  badly  after  operations  without  showing  definite  symp- 
toms of  sepsis  or  complications  pointing  to  disease  of  the  kidneys,  heart  or 
lungs,  although  all  of  these  organs  may  be  under  suspicion.  There  may  be 
too  small  an  amount  of  urine  secreted  suggesting  the  likelihood  of  acute 
renal  congestion,  causing  a  fear  of  impending  uremia,  or  the  heart's  action 
may  be  somewhat  erratic  or  weak,  causing  one  to  fear  that  a  myocarditis 
may  have  been  overlooked.  Again,  there  may  be  accelerated  respiration 
indicating  the  possibility  of  an  incipient  pneumonia,  or  these  conditions  may 
exist  simultaneously  with  or  without  beginning  sepsis. 

In  our  own  experience  it  has  seemed  as  though  one  can  usually  antici- 
pate this  condition  by  a  careful  preliminary  examination,  together  with  a 


GENERAL     SURGICAL     CONSIDERATIONS  21 

careful  consideration  of  the  patient's  history,  and  especially  that  part  of  the 
history  which  relates  to  the  habits  of  life,  especially  as  regards  nervous  strain 
and  rest  and  the  use  of  alcohol,  tobacco  and  drugs ;  also  the  consideration 
of  the  quantity  and  quality  of  food  accustomed  to. 

On  the  other  hand  the  patient  can  often  be  protected  from  danger  by 
a  preliminary  course  of  hygienic  living  especially  where  there  is  no  great 
urgency,  and  the  operation  is  for  chronic  conditions. 

Laxatives  Before  Operations. 

We  have  used  various  forms  of  cathartics  previous  to  operations  at  dif- 
ferent times,  but  have  now  come  to  depend  on  but  one  cathartic  before 
operation  in  all  cases  in  which  there  is  present  no  form  of  peritonitis  or 
intestinal  obstruction.  In  the  latter  classes  of  cases  any  form  of  cathartics 
or  laxatives  should  be  condemned  most  vigorously.  In  all  other  cases 
two  ounces  of  castor  oil  is  given  to  adult  patients,  one-half  this  dose  to 
children  from  four  to  twelve  years  of  age,  and  proportionately  less  to 
younger  children  and  infants. 

High  Blood  Pressure. 

The  matter  of  abnormally  or  excessively  high  blood  pressure  does  not 
have  to  be  considered  in  patients  less  than  thirty-five  years  of  age  and  only 
in  rare  instances  in  patients  less  than  fifty-five  years  of  age.  It  should,  how- 
ever, be  borne  in  mind  that  it  is  in  fairly  young  patients  that  one  is  most 
likely  to  get  into  difficulties  from  this  cause,  because  it  is  much  easier  to 
overlook  this  source  of  danger  in  the  relatively  young  patient  than  in  those 
more  advanced  in  years. 

Many  of  these  patients  will  bear  an  operation  which  involves  only  a 
small  amount  of  trauma  without  any  difficulty,  while  they  succumb  to  ex- 
tensive operations  in  which  they  are  subjected  to  the  influence  of  anesthetics 
for  a  considerable  period  of  time.  In  such  cases  the  nervous  strain  accom- 
panying local  anesthesia  is  also  borne  very  badly,  consequently,  there  is  not 
much  choice  between  these  two  evils.  It  is,  however,  often  possible  to  per- 
form these  operations  in  two  or  more  stages.  If  such  a  patient,  for  instance, 
has  a  tumor  and  gall  stones,  or  a  hernia  and  some  other  pathological  condi- 
tion, or  any  two  of  any  number  of  other  combinations,  it  is  best  to  perform 
one  of  these  operations  at  a  time.  In  intracranial  affections,  for  instance, 
it  is  better  to  make  a  temporary  skin  and  bone  flap,  control  the  hemorrhage, 
carefully  replace  the  flaps  and  complete  the  operation  when  the  patient's 
condition  has  been  thoroughly  restored. 

It  is  not  necessary  to  go  into  details  at  this  point,  the  general  principle 
involved  simply  contemplates  a  plan  by  which  as  small  a  burden  as  possi- 
ble is  placed  upon  a  patient  who  is  not  in  a  good  condition  to  carry  addi- 
tional burdens.  These  patients  usually  bear  repeated  light  burdens  better 
than  single  heavy  ones. 

INFANCY. 

Infants  Bear  Operations  Well. 

The  same  seems  to  be  true  of  the  other  extreme  in  age.  Infants  bear 
operations  well,  provided  they  are  not  too  long  continued,  nor  accompanied 
by  too  great  loss  of  blood. 

Guard  Against  Hemorrhage. 

The  mortality  in  infants  following  operations  is  due  largely  to  shock 


22  GENERAL     SURGICAL     CONSIDERATIONS 

caused  by  the  trauma  of  the  operation  and  hemorrhage.  It  is  important  to 
remember  that  an  amount  of  trauma  which  would  not  have  to  be  considered 
in  adults  because  of  the  size  of  the  patient  and  the  consistency  of  the  tissues, 
may  result  in  serious  shock  in  infants  and  young  children.  Again,  the  same 
amount  of  blood  lost  in  a  child  weighing  fifteen  pounds  is  ten  times  as  seri- 
ous as  the  same  amount  lost  in  an  adult  weighing  one  hundred  and  fifty 
pounds. 
Operate  Rapidly. 

A  surgeon  who  is  slow  but  violent  in  his  manipulations  should  there- 
fore choose  only  adult  patients.  Operations  upon  infants  should  be  carefully 
planned,  quickly  executed,  and  with  the  least  possible  amount  of  trauma  and 
smallest  possible  loss  of  blood. 

Quite  a  few  children  and  infants  die  after  operation  from  pneumonia. 
This  can,  however,  be  almost  completely  eliminated  by  reducing  the  time 
of  operation  to  a  minimum  and  permitting  the  child  to  almost  completely 
come  out  of  the  anesthesia  by  the  time  the  operation  is  finished  and  by  ap- 
plying the  sutures  so  that  the  patient  can  move  about  freely  and  if  pos- 
sible to  sit  up  in  bed  soon  after  the  operation  has  been  terminated. 

Protection  of  the  Mother  in  the  After-Care. 

In  nurslings  it  is  moreover  most  important  to  secure  the  co-operation 
of  the  mother.  The  latter  should  never  be  permitted  to  undertake  the  care 
of  the  infant  after  a  serious  operation,  because  the  resulting  fatigue  and 
anxiety  will  surely  have  a  harmful  effect  upon  the  milk,  and  the  child  will 
consequently  suffer  from  gastric  disturbances  in  addition  to  those  naturally 
resulting  from  the  effects  of  the  operation.  . 

These  conditions  should  be  carefully  explained  to  the  mother  so  that 
her  natural  anxiety  for  the  safety  of  her  child  will  serve  to  improve  its 
prognosis  rather  than  to  reduce  its  chances.  In  many  instances  we  have  seen 
a  worn-out  mother  improve  remarkably  in  health  during  the  time  her  child 
has  been  confined  to  the  hospital,  and  with  the  improvement  of  her  general 
condition  the  child's  nutrition  is  always  greatly  improved.  The  mother 
should  not  live  in  the  hospital  but  conveniently  near  so  that  she  can  come 
to  the  hospital  at  regular  intervals,  varying  from  three  to  four  hours,  ac- 
cording to  the  age  and  condition  of  the  child. 

It  is  well  for  the  mother  to  have  a  definite  program  which  she  must 
follow  absolutely.  She  should  never  be  permitted  to  carry  or  hold  the  child 
except  while  actually  nursing  it.  Before  she  nurses  the  child  the  first  time 
in  the  morning  she  should  drink  a  pint  of  hot  milk  or  gruel  so  that  she  will 
not  be  in  a  depressed  condition  during  the  act  of  nursing.  After  nursing 
the  child  she  may  take  a  walk  in  the  open  air,  then  breakfast  liberally,  then 
rest  for  at  least  one  hour  and  return  to  the  child  just  in  time  for  the  next 
feeding.  Her  luncheon  is  again  followed  by  a  period  of  rest.  In  the  mid- 
dle of  the  afternoon  the  mother  may  take  some  nourishment,  preferably  a 
pint  of  milk,  with  bread.  She  may  take  a  liberal  meal  in  the  evening,  nurs- 
ing the  child  at  regular  intervals  varying  from  two  to  four  hours  according 
to  the  requirements  of  the  little  patient,  the  time  of  nursing  being  so  ar- 
ranged that  the  mother  can  obtain  from  seven  to  ten  hours  of  uninterrupted 
sleep.  She  should  always  take  some  nourishment  before  retiring.  Both  the 
mother  and  the  child  will  form  regular  habits  during  the  time  the  latter  is 
in  the  hospital  and  the  health  of  the  former,  and  the  nutrition  of  the  latter 
invariably  improve  to  a  marked  extent. 


GENERAL     SUKCilCAL     CONSIDERATIONS  23 

LOSS  OF  BLOOD. 

Importance    of   Safeguarding    Blood    S     upply. 

For  all  patients  it  is  wise  to  guard  against  the  loss  of  an  unnecessary 
amount  of  blood ;  but  this  is  especially  true  in  children  and  in  those  ad- 
vanced in  years,  because  many  of  these  do  not  recover  readily  from  an 
anemia  caused  by  a  great  exsanguination.  Every  operation  should  be 
carefully  planned  with  the  idea  of  preventing  the  unnecessary  loss  of  blood. 
Usually  this  end  can  be  accomplished  if  the  surgeon  lays  out  a  thoroughly 
systematic  course  for  his  operation,  because  the  source  of  hemorrhage  in 
every  operation  can  be  anticipated  by  applying  two  pair  of  forceps  to  each 
one  of  the  larger  vessels  before  it  is  severed  and  quickly  applying  clamps  to 
the  oozing  surfaces  as  the  operation  progresses  in  all  parts  of  the  body  in 
which  it  is  not  possible  to  entirely  prevent  hemorrhage  during  operation 
by  the  application  of  elastic  constriction.  If  the  surgeon  has  assistants  who 
have  learned  how  to  concentrate  their  attention  during  the  progress  of  the 
work,  much  is  gained  in  saving  blood  because  they  will  anticipate  the  sur- 
geon and  will  stop  all  hemorrhage  almost  instantly  in  those  points  in  which 
one  cannot  apply  forceps  before  severing  the  tissues. 

Slow  vs.  Rapid  Operating. 

There  are  two  errors  which  will  be  referred  to  again  presently  which 
the  surgeon  should  not  fall  into  in  his  attempts  to  prevent  loss  of  blood,  name- 
ly ;  too  rapid  and  too  slow  operation.  The  former  is  certain  to  lead  to 
calamity  occasionally  in  individual  cases,  although  the  majority  of  patients 
will  undoubtedly  do  well  under  very  rapid  technique.  The  slow  operation 
is  especially  likely  to  result  in  secondary  trouble  like  pneumonia  and  ne- 
phritis. 

It  is  important  to  take  a  reasonable  attitude  regarding  this  feature.  It 
is  possible  to  be  guilty  of  insane  haste  on  the  one  side  and  of  imbecile 
deliberation  on  the  other. 

OBESITY. 
Special  Care  Required. 

Patients  who  are  very  obese,  especially  those  beyond  middle  age,  require 
particular  consideration.  Their  resistance  is  diminished ;  they  recover  from 
shock  less  speedily ;  they  frequently  take  the  anesthetic  badly,  and  they  are 
more  liable  to  pneumonia  following  the  use  of  ether  than  patients  with  a 
normal  amount  of  fat.  Still  it  is  only  seldom  that  the  presence  of  obesity 
will  contra-indicate  an  operation  entirely.  Ordinarily  it  would  simply  indi- 
cate the  use  of  especial  care. 

In  many  of  these  patients  it  is  possible  to  reduce  the  weight  to  a  great 
extent  before  operation  by  following  a  systematic  plan  of  dieting,  combined 
with  exercise  and  baths  to  be  described  presently. 

In  planning  the  operation  in  these  cases  the  wound  should  be  so  sutured 
that  they  can  move  about  freely  in  bed  and  if  possible  sit  up  directly  after 
the  operation,  especially  for  the  purpose  of  preventing  hypostatic  pul- 
monary congestion  following  operation. 

TUBERCULOSIS. 

General  Operations  Inadvisable. 

In  patients   suffering-  from  tuberculosis  an  operation  is  usually  borne 


24  GENERAL     SURGICAL     CONSIDERATIONS 

well  if  it  removes  the  tubercular  tissue.  If  this  is  not  removed  by  the  op- 
eration such  patients  frequently  do  not  do  well,  consequently  the  presence 
of  tuberculosis  is  only  a  centra-indication  to  operation  in  a  limited  variety 
of  cases. 

In  patients  suffering  from  pulmonary  tuberculosis  long-continued  op- 
erations are  contra-indicated  chiefly  because  the  disease  in  the  lungs  is  likely 
to  make  progress  during  the  time  that  the  patient  is  recovering  from  the 
depressing  effects  of  the  operation. 

It  is  difficult  to  say  whether  ether  anesthesia  is  really  in  itself  harmful 
in  these  cases.  It  has  been  suggested  that  anesthesia  by  inhalation  be  not 
employed  in  such  instances  and  that  local,  spinal  or  rectal  anesthesia  be  sub- 
stituted in  all  cases  in  which  pulmonary  tuberculosis  is  present. 

Preliminary  General  Treatment. 

It  is  generally  possible  to  place  these  patients  under  preliminary  hy- 
gienic, diatetic  and  often  under  climatic  treatment  for  the  cure  of  the  pul- 
monary tuberculosis  before  they  are  subjected  to  surgical  operations.  In 
many  the  local  condition,  if  it  is  also  due  to  tuberculosis  without  mixed  in- 
fection, will  recover  simultaneously  with  the  pulmonary  tuberculosis.  This 
is  true  especially  in  cases  suffering  from  joint  tuberculosis  in  which  perfect 
immobilization  has  been  accomplished  while  the  pulmonary  condition  is 
under  the  above  form  of  treatment. 

CACHEXIA  DUE  TO   MALIGNANT  GROWTHS. 
A  Contraindication. 

Ordinarily  the  presence  of  cachexia  in  patients  suffering  from  malig- 
nant growths  is  a  distinct  centra-indication  to  operation  because  these  pa- 
tients do  not  bear  operations  well  and  with  few  exceptions  derive  very  little 
benefit  therefrom.  This  is,  however,  not  the  case  in  ulcerating  carcinoma 
in  which  the  cachexia  is  clue  largely  to  the  absorption  of  products  of  de- 
composition, which  can  often  be  safely  eliminated  by  an  operation. 

Again,  in  cases  in  which  the  malignant  growth  interferes  with  nutri- 
tion by  obstructing  some  portion  of  the  alimentary  canal  this  rule  does  not 
always  hold  good,  because  frequently  the  improved  nutrition  greatly  over- 
balances the  traumatism  resulting  from  the  operation. 

In  a  general  way  it  may  be  stated  that  so  long  as  the  condition  in  a 
given  case  seems  to  indicate  the  possibility  of  removal  of  all  of  the  malig- 
nant tissue  the  operation  is  warranted  provided  it  does  not  necessitate  the 
removal  of  a  part  of  the  body  which  is  necessary  for  the  continuance 
of  life.  In  some  cases  the  apparent  cachexia  can  be  removed  before  opera- 
tion by  appropriate  treatment. 

Example:    Gastric  Carcinoma. 

In  cases  of  carcinoma  of  the  stomach,  for  instance,  the  patient  fre- 
quently absorbs  a  quantity  of  decomposing  substance  during  a  considerable 
period  of  time,  and  as  a  result  of  this  his  condition  becomes  markedly 
cachectic.  In  many  such  the  tumor  may  still  be  confined  to  the  stomach.  If 
operated  at  once  the  resistance  of  the  patient  may  be  so  low  on  account  of 
the  condition  described  above  that  he  may  succumb  to  the  shock  of  the 
operation.  If  the  same  patient  has  gastric  lavage  performed  three  times 
daily  at  intervals  of  eight  hours,  or  four  times  daily  at  intervals  of  six 


GENERAL     SURGICAL     CONSIDERATIONS  25 

hours,  two  hours  after  receiving  some  concentrated  sterile  food,  his  condi- 
tion will  improve  to  a  surprising  extent  in  from  one  to  two  weeks. 

The  ingestion  of  small  doses  of  oil  of  eucalyptus,  from  five  to  twenty 
drops  after  each  gastric  lavage,  is  of  further  aid  in  the  disinfection  of  the 
stomach  cavity.  In  the  meantime  the  patient's  strength  can  be  further  sup- 
ported by  giving  rectal  feeding  in  the  form  of  one  ounce  of  the  various  con- 
centrated liquid  predigested  foods  in  the  market  dissolved  in  three  ounces  of 
normal  salt  solution,  administered  slowly  as  an  enema  through  a  small 
rubber  catheter  introduced  into  the  rectum  for  a  distance  of  not  more  than 
three  inches. 

One  Danger  in  Preliminary  Treatment. 

One  danger  must  be  borne  in  mind  in  connection  with  this  form  of 
preliminary  treatment.  In  many  instances  the  general  welfare  improves  to 
so  marked  an  extent  that  some  doubt  may  arise  concerning  the  original 
diagnosis,  and  this  may  give  rise  to  postponement  of  the  operation  until 
the  carcinoma  has  advanced  to  a  hopeless  point.  It  is  always  bad  practice 
to  postpone  operations  of  any  kind  in  patients  suffering  from  malignant 
growths,  because  after  such  a  growth  has  once  begun  to  invade  the  sur- 
rounding tissues. there  is  no  stopping  in  its  progress  except  by  its  complete 
removal  or  by  the  death  of  the  patient,  hence  the  importance  of  not  losing 
valuable  time  before  an  attempt  is  made  to  remove  the  growth. 

SPEEDINESS  IN  OPERATING. 

Two  Viewpoints. 

The  question  of  time  is  of  sufficient  importance  to  demand  some  con- 
sideration. It  is  only  necessary  to  look  upon  an  operation  from  the  two 
sides  which  have  a  bearing  in  order  to  come  to  a  proper  estimation  of  the 
importance  of  this  element:  I.  from  the  merely  mechanical  or  technical  point 
of  view,  and,  2,  from  the  point  of  applying  this  to  the  patient. 

From  the  technical  standpoint  it  is  plain  that  a  skilled  mechanic  not 
only  does  his  work  well,  but  accomplishes  it  in  a  relatively  short  time,  while 
an  unskilled  mechanic  will  have  much  less  satisfactory  results  by  taking  a 
much  longer  time;  skill,  accuracy  and  facility  naturally  going  hand  in  hand 
in  bringing  about  the  highest  possible  outcome. 

Careful  Haste. 

However,  a  hasty  mechanic  may  complete  a  badly-constructed  product 
in  a  relatively  short  period  of  time  ;  and  it  is  consequently  necessary,  from  a 
purely  technical  standpoint,  to  distinguish  clearly  between  speed  which  is 
the  result  of  skill  and  dexterity,  and  speed  resulting  from  carelessness, 
wanton  haste  and  lack  of  thoroughness.  From  a  strictly  technical  stand- 
point, then,  we  have  a  right  to  demand  the  greatest  speed  compatible  with 
careful,  thorough  work.  AYhen  we  come  to  apply  this  directly  to  the  pa- 
tient still  further  elements  will  be  introduced. 

Flasty  and  careless  work  is  more  harmful  because  of  the  needless 
traumatism  which  it  is  likely  to  produce,  and  this  may  in  turn  result  in 
shock  or  in  the  injury  of  structures  needlessly  implicated.  The  patient 
may  not  receive  the  full  amount  of  benefit  through  lack  of  thoroughness, 
some  conditions  being  overlooked  and  neglected  on  account  of  undue  haste. 


26  GENERAL     SURGICAL     CONSIDERATIONS 

Dangets  of  Slowness. 

On  the  other  hand,  it  is  almost  equally  bad  to  prolong  an  operation 
needlessly,  because  this  exposes  the  patient  to  a  number  of  unnecessary  dan- 
gers: i,  A  prolonged  anesthesia  increases  the  danger  immediately,  and  many 
times  patients  will  recover  from  a  short  anesthesia  with  scarcely  any  dis- 
comfort, while  they  will  suffer  greatly  from  nausea  and  vomiting  after  a 
prolonged  anesthesia.  If  ether  is  employed,  a  prolonged  anesthesia  is  much 
more  likely  to  be  followed  by  bronchitis  or  pneumonia  than  a  short  one. 
2,  Other  things  being  equal,  the  amount  of  shock  is  proportionate  to  the 
relative  time  consumed  in  the  operation.  3,  Infection  is  more  likely  to  occur 
in  a  wound  which  has  been  exposed  to  manipulations  for  a  long  time. 

Local  Anesthesia   Favors  Deliberateness. 

In  operations  performed  under  local  or  spinal  anesthesia  the  element 
of  time  is  of  course  very  much  less  important  than  with  general  anesthesia, 
provided  the  operation  is  completed  before  the  local  anesthetic  has  lost  its 
effect,  because  the  condition  of  the  nerves  in  the  field  of  operation  prevents 
shock  from  long  continued  manipulations  and  there  is  no  danger  from  post- 
operative pneumonia  unless  the  patient  has  been  unnecessarily  exposed  to 
cold  or  moisture.  Of  course,  if  the  patient  has  been  chilled  during  the 
operation,  this  may  give  rise  to  shock  and  pneumonia  may  occur  after  the 
operation. 

Reasonable  Speed  in  Operating. 

Then  again,  there  are  many  cases  in  which  the  element  of  time  is  of  no 
real  importance  because  the  procedures  are  so  simple,  and  some  patients  are 
so  vigorous  that  they  will  recover  even  if  they  are  not  given  the  best  possi- 
ble conditions.  It  seems,  however,  reasonable  to  demand  of  the  surgeon 
a  fair  amount  of  technical  skill  and  dexterity,  especially  as  there  are  in- 
stances in  which  the  lack  of  these  might  cause  the  death  of  the  patient.  It 
seems  foolish  to  hurry,  and  equally  so  to  prolong  an  operation  unnecessarily. 

There  are  two  tendencies  which  become  quite  prominent  in  some  hos- 
pitals and  clinics  which  we  believe  should  be  abandoned,  one  of  these  might 
be  characterized  as  insane  haste  in  performing  operations  and  the  other  as 
imbecile  deliberation.  It  is  difficult  to  say  which  of  these  is  the  more  repre- 
hensible. 

Of  course,  it  is  not  possible  for  all  surgeons  to  work  at  a  given  rate 
of  speed,  but  every  surgeon  should  strive  to  waste  no  time  and  without 
hurry  to  complete  each  operation  in  the  shortest  period  compatible  with 
thoroughness.  Roth  careless  handling  of  tissues  in  order  to  gain  speed  and 
useless  manipulation  while  wasting  time  should  be  avoided. 

TRAUMATISM. 

Importance  of  Reducing  Injury. 

There  can  be  no  doubt  of  the  importance  to  the  patient  of  reducing  the 
traumatism  incident  to  surgical  operations  to  a  minimum.  Even  though  the 
patient  be  asleep,  and  consequently  not  conscious  of  the  traumatism,  the 
amount  of  injury  done  to  his  tissues  is  a  definite  burden  placed  upon  him, 
and  the  less  this  burden  is  the  better  for  the  patient.  In  order  to  obtain 
this  minimum  of  traumatism  the  conditions  in  each  case  must  be  studied 
separately  and  the  operation  planned  accordingly.  It  is  often  possible  to 


GENERAL    SURGICAL     CONSIDERATIONS  2/ 

accomplish  the  same  result  through  a  small  as  through  a  large  incision, 
which  will  reduce  the  amount  of  traumatism ;  in  other  cases  it  would  re- 
quire much  crushing  of  the  tissues  in  a  small  wound  while  the  same  opera- 
tion could  be  accomplished  through  a  large  wound  without  this  added  in- 
jury. 

Above  all  things  a  surgeon  should  form  the  habit  never  to  manipulate 
tissues  needlessly  and  especially  not  to  manipulate  organs  which  are  not 
involved  and  which  may  readily  be  left  untouched. 

The  Typical  Operation. 

In  many  instances  much  traumatism  is  caused  by  the  surgeon  for  the 
purpose  of  securing  an  absolute  repair  of  a  given  lesion,  which  if  left  to 
itself  would  heal  spontaneously  with  a  better  result  and  at  less  expense  to  the 
powers  of  the  patient.  This  is  true  especially  of  the  newer  operations,  which 
are  usually  quite  complicated.  One  by  one  the  useless  elements  of  the 
operation  are  eliminated,  and  with  this  progress  much  of  the  traumatism  is 
discarded.  And  this  statement  is  also  true  not  only  of  the  individual  sur- 
geon who  naturally  accomplishes  any  given  operation  with  less  traumatism 
after  he  has  performed  it  repeatedly,  than  during-  his  first  attempts,  but 
there  is  always  developed  in  time  what  may  be  termed  a  fairly  normal  or 
typical  operation  from  which  experience  eliminates  most  of  the  useless  and 
practically  all  of  the  harmful  features.  Those  who  have  been  actively  en- 
gaged in  surgical  work  from  the  beginning  of  the  antiseptic  era  to  the  pres- 
ent time  have  had  an  excellent  opportunity  to  observe  this  process  of  evolu- 
tion in  surgical  technic  in  connection  with  most  of  the  operations  which 
have  attained  an  established  position  in  the  field  of  clinical  surgery. 

In  a  general  way  it  seems  proper  to  state  axiomatically  that  violent  sur- 
gery is  bad  surgery. 

HEMORRHAGE. 

Apply  Hemostasis  at  Once. 

Except  in  especially  anemic  patients  a  moderate  amount  of  blood  can 
be  lost  during  an  operation  without  causing  appreciable  harm,  but  it  is  we'll 
to  limit  the  amount  by  quickly  applying  hemostatic  forceps  to  all  bleeding 
points  the  moment  the  incision  is  made,  and  to  grasp  the  larger  vessels, 
whenever  possible,  between  two  pairs  of  forceps  before  they  are  severed ; 
in  all  operations  upon  the  extremities  to  elevate  the  latter  for  several  minutes 
and  then  to  constrict  them  above  the  area  of  operation  with  a  large  rub- 
ber tube  or  a  broad  rubber  band  drawn  about  the  part  a  number  of  times  and 
tied.  If  the  extremities  are  constricted  in  a  careless  manner  severe  harm 
can  be  done  especially  to  the  nerve  trunks.  It  is  wise  always  to  surround 
the  part  with  a  towel  folded  upon  itself  about  four  times  and  then  to  use  a 
soft  rubber  drainage  tube  at  least  one  inch  in  diameter  as  a  constrictor. 

The  Pneumatic  Constrictor. 

Recently  a  number  of  contrivances  have  been  introduced  which  are 
intended  to  accomplish  complete  constriction  of  the  blood  vessels  without 
endangering  the  nerves.  One  of  the  best  of  these  consists  of  an  adjustable 
pneumatic  tube  which  is  applied  about  the  extremity  at  the  desired  point 
and  adjusted.  It  is  then  inflated  with  air  to  the  degree  necessary  to  com- 
pletely obstruct  the  flow  of  blood  both  in  the  arteries  and  veins.  The  same 
apparatus  can  be  utilized  in  the  application  of  Bier's  local  congestion  treat- 


28  GENERAL     SURGICAL     CONSIDERATIONS 

ment  to  be  discussed  later.  It  is  plain  that  no  harm  can  be  done  to  the 
nerves  in  an  extremity  exposed  to  the  pressure  from  such  a  pneumatic  con- 
strictor. 

Hemostatic  Forceps  and  Clamps. 

It  is  usually  not  difficult  to  reduce  the  loss  of  blood  to  a  very  small 
amount  without  consuming  a  great  deal  of  time.  If  strong  hemostatic  for- 
ceps are  used  the  ends  of  the  blood  vessels  will  be  crushed  sufficiently  to 
make  a  ligation  of  all  the  smaller  vessels  unnecessary.  It  is  well  to  leave  the 
forceps  in  place  until  the  operation  has  been  completed,  then  to  ligate  the 
larger  vessels  and  simply  to  remove  the  forceps  from  the  smaller  ones. 

Various  hemostatic  clamps  have  been  invented  for  the  purpose  of  con- 
trolling the  hemorrhage  during  and  after  operation  without  the  use  of  liga- 
tures, and  it  is  well  to  bear  this  feature  in  mind  in  purchasing  hemostatic 
clamps,  because  the  use  of  effective  instruments  of  this  kind  will  reduce  the 
time  of  operation  quite  sufficiently  to  merit  attention. 

Ligatures  Preferable  to  Torsion  or  Crushing. 

A  number  of  years  ago  the  use  of  such  clamps  seemed  especially  indi- 
cated because  ligature  material  was  not  generally  reliable.  This  is  no  longer 
the  case  as  catgut  can  now  be  easily  prepared  according  to  methods  to  be 
described  later  so  that  it  is  absolutely  safe.  For  this  reason  it  seems  fool- 
ish at  the  present  time  to  make  use  of  torsion  or  crushing  in  dealing  with 
the  larger  blood  vessels.  In  case  of  the  largest  ones  like  the  femoral  or 
axillary,  it  is  best  to  apply  two  catgut  ligatures  from  two  to  five  mm.  apart. 

Hemophilics. 

In  instances  of  hemophilia,  operations  should  always  be  avoided  if  at 
all  possible.  In  case  it  is  apparent  that  at  some  future  time  an  operation 
will  become  necessary  it  may  be  well  to  make  use  of  preliminary  treatment. 
In  several  cases  we  have  found  benefit  from  giving  these  patients  egg-albumin 
in  considerable  quantities,  using  the  whites  of  three  to  six  eggs  raw,  night 
and  morning  for  a  number  of  months.  The  administration  of  200  grms.  of 
ten  per  cent  solution  of  gelatine  internally  every  day  for  a  period  of  six 
months  has  been  found  beneficial  in  these  cases.  These  substances  can 
be  disguised  in  various  ways  to  secure  palatability. 

Pre-operation   Milk  Diet  Favors    Hemostasis. 

It  has  also  been  shown  experimentally  that  the  amount  of  bleeding  is 
much  less  in  patients  who  have  had  a  liberal  milk  diet  for  several  weeks 
previous  to  operation,  consequently  where  hemorrhage  is  feared  it  is  well 
to  place  the  patient  on  a  full  diet  of  milk  and  egg-albumin  and  only  enough 
other  food  to  keep  the  appetite  stimulated. 

Other  Remedies  to  Reduce  Hemorrhage. 

Several  remedies  have  been  much  used  prophylactically  to  reduce  hem- 
orrhage. Of  these  chloride  of  calcium  has  received  the  greatest  amount  of 
prominence  since  its  introduction  by  Mayo  Robson,  especially  in  the  surgery 
of  the  biliary  tract.  Robson  employs  this  remedy  both  before  and  after 
operation,  giving  thirty  grains  in  half  a  pint  of  water  three  to  six  times 
daily  by  mouth  for  two  or  three  days  before  the  operation,  and  sixty  grains 
in  a  pint  of  warm  water  by  rectum  thrice  daily  after  the  operation  for 
t\vo  or  three  clays,  or  longer.  \Ve  have  used  this  remedy  in  many  cases  but 
not  with  as  satisfactory  results  as  anticipated. 


GENERAL    SURGICAL     CONSIDERATIONS  2Q 

Ten-grain  doses  of  gallic  acid  given  every  two  hours  in  gelatin  capsules 
for  from  one  day  to  one  week  in  cases  in  which  it  has  seemed  desirable  to 
reduce  the  amount  of  hemorrhage  have  seemed  to  reduce  the  amount  of 
blood  lost  during  operation  to  a  very  marked  extent.  Where  it  does  not 
seem  wise  to  postpone  the  operation  more  than  a  few  hours,  we  have  given 
ten-grain  doses  of  gallic  acid  hourly  for  a  period  of  from  ten  to  fifteen 
hours  without  having  observed  any  harmful  effect  from  the  relatively  large 
amount  of  the  drug  in  a  short  period  of  time,  while  it  has  seemed  that  the 
effect  in  reducing  the  hemorrhage  has  been  quite  marked  even  under  these 
conditions. 

TEMPERATURE    OF   OPERATING   ROOM. 

The  atmosphere  in  an  operating  room  should  be  between  68  and  72  de- 
grees F.,  because  such  a  temperature  is  about  the  average  for  dwellings  in 
this  country  and  the  air  heated  to  this  point  is  comfortable  both  to  the  pa- 
tient and  the  operator.  If  lower  it  is  likely  to  be  cooler  than  the  patient 
is  accustomed  to  breathe,  if  warmer,  it  is  likely  to  be  oppressive  to  the  op- 
erator and  he  can  scarcely  be  expected  to  do  his  best  work  when  he  is 
practically  smothered  by  hot  air.  The  patient's  body  should  be  protected, 
except  at  the  field  of  operation,  and  this  need  not  be  so  large  as  to  cause 
chill.  It  is  well  to  place  hot  water-bags  about  a  patient  on  the  operating 
table  if  the  operation  is  expected  to  be  of  long  duration. 

Warm  Operating  Tables. 

Operating  tables  have  been  constructed  with  double  tops  which  can  be 
filled  with  water  heated  to  120  degrees  F.,  and  which  will  remain  warm 
throughout  the  operation,  or  which  can  be  kept  at  a  given  temperature  by 
the  use  of  an  electric  heater. 

Another  useful  contrivance  has  been  invented  in  the  form  of  a  flat 
rubber  mattress  which  fits  upon  the  top  of  the  operating  table  and  which 
is  filled,  before  the  patient  is  placed  upon  it,  with  water  heated  to  120  de- 
grees F.  This  is  exceedingly  simple  and  very  satisfactory. 

Another  plan  consists  in  a  row  of  incandescent  electric  lights  under- 
neath the  table  which,  when  lighted,  will  supply  the  proper  amount  of  heat. 

With  an  operation  of  less  than  one  hour's  duration  none  of  these  expe- 
dients is  necessary,  and  if  employed  in  cases  of  longer  duration,  the  sim- 
pler the  method  the  more  useful  it  is  in  practice. 

Influences  Affecting  Shock. 

It  was  thought  at  one  time  that  shock  was  caused  in  abdominal  op- 
erations by  the  exposure  of  the  intestines  to  a  temperature  so  much  below 
that  of  the  body,  but  this  objection  is  no  longer  tenable,  because  no  ab- 
dominal operator  exposes  the  intestines  to  the  atmosphere.  The  shock  re- 
ferred to  above  was  undoubtedly  clue  to  the  extensive  manipulations  of  intra- 
abdominal  organs  practised  at  that  time. 

If  all  of  these  conditions  are  properly  considered  as  a  matter  of  habit 
in  connection  with  surgical  work  and  means  of  correction  followed,  it  will 
be  found  that  the  post-operative  disturbances,  especially  those  due  to  shock, 
will  be  very  greatly  decreased. 

There  is  a  decided  difference  in  the  amount  of  shock  from  which  pa- 
tients suffer  after  similar  operations  performed  by  different  surgeons,  and  we 
believe  that  this  difference  is  due  larsrelv  to  the  fact  that  some  surgeons 


30  GENERAL  SURGICAL  CONSIDERATIONS 

habitually  apply  all  of  the  principles  involved  in  the  above  considerations 
which  bear  upon  limitation  of  shock,  while  others  as  habitually  disregard 
them. 

It  is  well  to  bear  in  mind  also  the  fact  that  there  is  much  less  likeli- 
hood of  exposure  of  intestines  to  the  air  when  they  are  empty  and  conse- 
quently in  a  thoroughly  collapsed  condition  at  the  time  of  the  operation 
than  if  they  are  distended  with  gas  to  a  varying  degree.  In  all  cases  in 
which  it  is  possible  to  make  preliminary  preparation  of  the  patient  it  is  possi- 
ble to  attain  this  condition,  by  giving  the  patient  two  ounces  of  castor  oil 
on  the  day  before  the  operation,  and  then  giving  him  nothing  to  eat  except 
broth  for  twenty-four  hours  previous  to  the  operation. 

Cathartics  to  be  Avoided  in  Peritonitis. 

Of  course,  the  giving  of  castor  oil,  as  well  as  all  other  forms  of  cathar- 
tics and  also  of  any  form  of  food,  is  absolutely  contraindicated  in  all  those 
suffering  from  any  form  of  peritonitis.  The  same  is  true  even  with  greater 
force  in  all  cases  of  intestinal  obstruction,  but  in  these  two  classes  of 
cases  the  gaseous  distension  can  be  most  effectually  relieved  by  carefully 
executed  gastric  lavage,  which  may  be  repeated  several  times  if  necessary, 
and  by  placing  absolutely  nothing  in  the  stomach,  not  even  water,  and  by 
giving  nourishment  exclusively  by  rectum,  preferably  by  the  use  of  an 
ounce  of  one  of  the  various  concentrated  predigested  liquid  foods  diluted 
with  three  ounces  of  normal  salt  solution  given  through  a  small  catheter  in- 
troduced into  the  rectum  not  more  than  three  inches.  It  is  best  to  pour  the 
fluid  into  a  funnel  or  a  glass  syringe  attached  to  the  catheter  and  to  permit 
it  to  enter  the  intestines  by  gravitation.  To  this  treatment  should  be  added 
the  proctolysis  of  normal  salt  solution  introduced  by  Murphy,  to  be  de- 
scribed later. 

In  every  case  belonging  to  these  two  classes  no  form  of  nourishment 
and  no  form  of  cathartics  should  ever  be  given  by  mouth. 

PREPARATION  OF  THE  PATIENT  FOR  OPERATION. 
Various  Steps. 

The  first  step  in  the  preparation  of  the  patient  after  entering  the  hos- 
pital, or  after  an  operation  has  been  decided  upon,  is  to  once  more  make 
a  thorough  examination  either  in  person,  or,  better  still,  by  an  equally  com- 
petent associate.  This  examination  should  be  made  independently  by  the 
associate  and  then  the  results  should  be  compared.  It  should  be  made  in  a 
systematic  way  and.  in  hospital  practice,  at  a  stated  period,  so  that  enough 
time  will  be  allotted  to  make  it  thorough.  It  is  extremely  easy  to  form  care- 
less routine  habits  unless  one  constantly  follows  a  definite  scientific  plan. 
It  does  not  matter  especially  what  plan  is  followed  so  long  as  it  is  compre- 
hensive. In  practice  we  have  found  the  following  scheme  to  be  most  satis- 
factory : 

r.      Family  history. 
2      Personal  history. 

fa)      Previous  illness,  etc. 

('b)      Present  illness. 
3.      Present  condition. 

(a)  General  condition,  development,  nutrition,  weight. 

(b)  Condition  of  skin. 


GENERAL     SURGICAL     CONSIDERATIONS  31 

1 .  Complexion. 

1.  Anemia. 

2.  Hyperemia. 

3.  Cyanosis. 

4.  Icterus. 

5.  Pigmentation. 

2.  Degree  of  moisture. 

3.  Degree  of  surface  heat.  Local  or  general. 

4.  Edema. 

5.  Emphysema. 

6.  Subcutaneous  hemorrhage. 

7.  Collateral  circulation. 

8.  Trophic  disturbances. 

(c)  Examination  of  chest. 

1.  Shape.    General  type. 

2.  Frequency  and  rhythm  of  respiratory  movements. 

3.  Excursion. 

(a)  Degree. 

(b)  Symmetry. 

4.  Palpation,  percussion  and  auscultation  of  chest  in  order  to 
determine  condition  of  heart  and  lungs. 

(d)  Examination  of  pulse  as  to  frequency,  rhythm,  strength,  com- 

pressibility and  condition  of  arterial  walls. 

(e)  Inspection,  palpation  and  percussion  of  abdomen. 

(f)  Examination  of  urine,  chemical  and  microscopical. 

(g)  Temperature. 

IN    SPECIAL   CASES. 

A.  Examination  of  eye.  External  and  ophthalmoscopic. 

B.  Examination  of  mouth,  pharynx  and  esophagus. 

C.  Examination  of  larynx,  laryngoscopic  and  functional. 

D.  Examination  of  nose. 

E.  Examination  of  stomach.     Size,  position,  functional  activity.  Chemical 

examination  of  stomach  contents. 

F.  Examination  of  feces. 

G.  Examination  of  blood. 

H.     Examination  of  nervous  system. 

I.      Examination  per  rectum,  per  vagina. 

J.      Exhaustive  examination  of  the  diseased  part  or  location. 

It  is  true  that  this  plan  increases  the  amount  of  labor  materially  and 
that  it  is  only  very  seldom  that  any  new  facts  are  determined  by  the  second 
examination,  but  it  is  just  in  the  few  cases  that  it  proves  to  be  of  the 
greatest  importance. 

Value  of  Conjoint  Diagnosis. 

Another  element  of  considerable  value  might  be  mentioned.  If  the  sur- 
geon knows  that  all  of  his  cases  are  to  be  examined  thoroughly  by  an  equally 
competent  colleague  or  assistant,  he  is  not  so  prone  to  become  careless  in 
his  personal  examinations  as  his  work  accumulates.  This  is  one  of  the 
most  common  causes  of  reduction  in  the  success  of  surgeons  who  have  been 
eminently  successful,  Aside  from  the  natural  tendency  with  advancing 


32  GENERAL    SURGICAL     CONSIDERATIONS 

years  to  give  less  and  less  attention  to  details  in  the  general  planning  and 
management  of  the  work,  nothing  is  so  certain  to  displace  the  older  mem- 
bers of  the  surgical  profession  as  a  tendency  to  make  a  less  thorough  diag- 
nosis as  the  years  accumulate. 

On  the  other  hand  nothing  can  be  of  greater  importance  in  the  de- 
velopment of  the  younger  surgeon  than  an  opportunity  to  make  a  large  num- 
ber of  careful,  systematic,  clinical  examinations  in  cases  which  have  been  or 
are  to  be  carefully  examined  by  a  surgeon  of  vast  experience  and  to  be 
compelled  to  make  an  independent  diagnosis  in  these  cases. 

SPECIAL  METHODS   OF  EXAMINATION. 

During  the  past  few  years  a  number  of  methods  have  been  developed 
for  the  examination  of  patients  by  the  use  of  various  vaccines  and  by  various- 
ly prepared  blood  sera. 

In  the  diagnosis  of  tuberculosis,  syphilis,  carcinoma  and  sarcoma  much 
valuable  work  has  been  done.  Many  of  these  methods  are  undergoing  such 
rapid  changes  that  it  will  not  be  wise  to  describe  them  here,  because  better 
methods  than  any  now  in  use  will  undoubtedly  be  advanced  in  the  current 
literature  before  many  months.  It  should  be  stated,  however,  that  all  of 
these  procedures  are  worthy  of  much  attention  and  should  be  considered  at 
least  when  they  confirm  a  diagnosis  made  by  means  of  old  methods  of  ex- 
amination. 

TESTS   FOR  TUBERCULOSIS. 

In  suspected  cases  of  tuberculosis  in  which  no  infective  material  can  be 
obtained  for  demonstration  of  tubercle  bacilli  tests  are  of  great  value. 

Tuberculin. 

i.  Temperature  test:  Koch's  old  tuberculin  which  has  been  carefully 
standardized  by  comparison  with  tuberculin  of  a  known  strength,  should  be 
used.  If  the  tuberculin  is  prepared  according  to  Koch's  methods  and  stand- 
ardized by  Ott's  method,  a  normal  person  will  not  show  a  reaction  with  a 
dose  of  .010  c.c.  of  the  original  tuberculin.  For  an  adult  .0005  c.c.  is  a  safe 
initial  dose.  It  is  best,  however,  to  give  at  first  either  .0001  or  .0002  c.c.  If 
these  do  not  produce  a  reaction  the  following  doses  should  be  given — .001 
c.c..  .003  c.c.,  .005  c.c.,  and  .008  c.c.,  or  even  .01  c.c. 

In  considering  the  dose  to  give,  it  is  necessary  to  take  into  consideration 
the  age,  sex,  physical  condition,  together  with  the  duration  and  extent  of 
the  disease.  In  children  .0001  c.c.  is  a  safe  initial  and  .003  c.c.  a  safe  maxi- 
mal dose. 

Technique  of  Tuberculin  Injection. 

Before  use,  the  tuberculin  must  be  diluted,  which  is  best  done  by  the 
physician.  A  pipette  graduated  to  hundredths  of  a  c.cm.,  and  a  graduated 
cylinder,  are  necessary  to  make  the  proper  dilution.  A  solution  of  25  per 
cent,  phenol  in  physiological  salt  solution  is  the  best  diluent.  If  the  salt 
solution  is  used  alone  it  must  be  prepared  before  each  injection.  The  hypo- 
dermic syringe,  needles,  pipettes,  cylinders,  etc.  should  be  carefully  sterilized. 
The  skin  should  be  thoroughly  cleansed  with  95  per  cent,  alcohol  before 
and  after  the  injection.  The  injection  is  best  made  into  the  deep  muscles  of 
the  back  rather  than  subcutaneously.  A  sterile  pad  is  then  placed  over  the 
point  of  injection  and  allowed  to  remain  at  least  twenty-four  hours. 


(iliNERAL     SURGICAL     CONSIDERATIONS  33 

Reaction. 

There  is  a  rise  of  temperature  i — 2  degrees  about  eighteen  to  twenty- 
four  hours  after  the  injection.  It  is  necessary  to  take  the  temperature  for 
two  or  three  days  before  and  after  the  injection. 

Contraindications. 

The  method  should  never  be  employed  in  cases  in  which  a  positive 
diagnosis  can  be  made  without,  because  it  is  in  this  class  of  cases  that  one 
sometimes  causes  violent  reactions  which  may  have  a  depressing  effect  upon 
the  patient. 

It  should  not  be  used  when  the  patient  is  temporarily  below  his  usual 
condition,  or  when  he  is  suffering  from  any  acute  disturbance,  especially  if 
this  is  accompanied  by  an  elevation  of  temperature. 

One  minim  of  tuberculin  used  as  indicated  is  mixed  with  one 
ounce  of  a  one-half  per  cent  carbolic  acid  solution.  Ten  drops  of  this  solu- 
tion is  equivalent  to  one-tenth  of  one  milligram  of  tuberculin. 

Rotch  and  Floyd  .Method. 

Rotch  and  Floyd's  method  of  preparing  the  tuberculin.  One  c.c.  of 
Koch's  old  tuberculin  is  added  to  999  c.c.  of  boiled  distilled  water ;  i 
c.c.  of  this  solution  equals  i  milligram.  The  dose  of  this  solution  for  an  in- 
fant or  child  is  from  2  to  5  milligrams,  according  to  the  age.  Moeller, 
with  his  large  experience,  formulates  the  following  rules  for  the  use  of 
tuberculin  in  the  diagnosis  of  tuberculosis,  after  noting  contraindications  for 
its  employment,  such  as  fever,  hysteria,  recent  hemoptysis  and  epilepsy.  He 
begins  usually  with  .1  to  .2  milligrams,  obtaining  this  quantity  by  dilution  as 
follows : 

(a) 

i   c.c.  of  tuberculin  -f-  9.9  c.c.  of  .5  per  cent,  carbolic  acid — i  c.c.  of  this  = 
.01  gram  tuberculin. 

(b) 

i  c.c.  of  (a)  dilution  and  9  c.c.  of  .5  per  cent,  carbolic  acid — i  c.c.  of  this 
=  .001  gram  tuberculin. 

(c) 

i   c.c.  of   (b)    -|-  9  c.c.  of  .5  per  cent,  carbolic  acid — i   c.c.  =  =  .1   mmgm. 
of  tuberculin. 

(d) 

i   c.c.  of  (b)  ~j-  4  c.c.  of  .5  per  cent,  carbolic  acid — i  c.c.  =  .2  mmgm.  tu- 
berculin. 

(e) 

i   c.c.  of  (b)  -f-  2  c.c.  of  .5  per  cent,  carbolic  acid — i  c.c.  =  0.3  mmgm.  tu- 
berculin. 

TUBERCULIN    INOCULATION,    OR    VON    PIRQUET'S    TEST. 

About  two  drops  of  diluted  tuberculin  (old)  is  placed  on  the  skin  and  a 
small  scarification  is  made  with  a  sterile  lancet  through  the  drop. 

Method. 

In  this  particular  method  make  a  25  per  cent,  solution  of  old  tuberculin 
in  salt  solution.  A  similar  dilution  is  used  in  which  one  volume  of  a  5 


34  GENERAL    SURGICAL    CONSIDERATIONS 

per  cent,  solution  of  carbolic  acid  in  glycerin  is  substituted  for  one  of  the 
volumes  of  salt  solution.  Place  two  drops,  one  of  each  solution  separated 
from  each  other  by  a  space  of  two  inches,  on  the  outside  of  the  arm,  which 
should  be  prepared  as  is  customary  for  vaccination.  A  small  lancet  with  a 
dull  tip  which  is  about  one-sixteenth  of  an  inch  wide  and  placed  vertically  in 
a  metal  handle  is  used  to  abrade  the  skin  through  the  vaccine  drops  by  a  ro- 
tary motion,  removing  only  the  upper  layers  of  epidermis.  The  tip  is  then 
cleaned  and  at  a  point  midway  between  the  vaccination  marks  a  third  abra- 
sion is  made  without  any  tuberculin  being  applied  to  serve  as  a  control. 

If  the  reaction  is  positive  a  papule  varying  in  size  from  5  to  20  mm.  in 
diameter,  at  first  bright-red,  later  becoming  a  dark-red  with  a  slight  areola, 
will  appear  at  either  vaccination  point  in  the  first  twenty-four  hours,  oc- 
casionally this  does  not  appear  until  forty-eight  hours. 

TECHNIQUE  FOR  MICROSCOPICAL  EXAMINATION  OF  BLOOD. 

Obtaining  the  Blood  from  the  Patient. 

For  microscopical  examination  the  blood  is  preferably  obtained 
from  the  lobe  of  the  ear,  which  is  cleansed  thoroughly  with  alcohol  on  a 
sponge,  it  is  then  wiped  dry  with  sterile  cotton,  rubbing  rather  vigorously  so 
as  to  produce  a  slight  hyperemia.  The  style  of  needle  to  be  used  is  of  lit- 
tle importance.  It  should  be  kept  immersed  in  alcohol  when  not  in  use. 
The  point  of  the  needle  is  inserted  into  the  inferior  surface  of  the  most 
dependent  part  of  the  lobe,  far  enough  to  cause  the  blood  drop  to  form 
without  using  pressure.  The  first  drop  is  wiped  away.  The  next  drop  is 
employed  to  determine  the  hemoglobin.  For  this  purpose  the  Tallquist 
hemoglobin  scale  is  used.  A  bit  of  the  paper  from  the  book  (which  accom- 
panies scale)  is  held  in  apposition  with  the  freshly  formed  droplet.  This  is 
allowed  to  dry  (which  requires  but  a  moment)  and  the  color  is  then  matched 
according  to  the  scale.  This  is  accurate  enough  for  all  practical  purposes. 

The  Thoma-Zeiss  Apparatus. 

The  next  step  is  to  fill  the  red  blood  counter  pipette.  The  Thoma- 
Zeiss  apparatus  is  here  used.  A  fresh  drop  is  allowed  to  form ;  the  tip  of 
the  pipette  is  placed  against  the  drop  (never  touching  the  ear)  the  blood 
is  sucked  up  to  the  mark  0.5  (precision  is  essential),  the  tip  is  wiped  off  and 
the  pipette  is  plunged  into  normal  NaCl  solution;  the  pipette  is  filled  with 
this  up  to  the  mark  101  and  then  twirled  about  so  that  the  salt  solution  and 
blood  become  intimately  mixed.  By  this  procedure  hemolysis  and  crenation 
are  prevented  and  the  blood  is  diluted  200  times.  The  next  step  is  to  fill  the 
leucocyte  counter.  A  fresh  drop  is  allowed  to  form — the  leucocyte  pipette  is 
filled  with  blood  to  the  mark  0.5  and  the  tip  is  cleansed  and  the  pipette  is  then 
filled  to  the  mark  1 1  with  3  per  cent,  acetic  acid.  The  acetic  acid  dissolves 
the  hemoglobin  out  of  the  red  cells.  A  slight  inaccuracy  in  filling  this  pipette 
will  cause  a  great  error  in  the  final  result.  The  dilution  is  I — 20  in  the 
pipette.  For  making  a  differential  count,  a  drop  of  blood  is  allowed  to  fall 
on  the  end  of  a  glass  slide.  The  slide  must  be  absolutely  clean  and  free 
from  fat,  etc.  The  drop  should  be  a  small  one.  It  is  spread  according  to  the 
diagram. 

A  bit  of  cotton  is  placed  against  the  patient's  ear  to  catch  a  drop  or  two 
which  may  ooze  out.  The  blood  is  now  ready  for  microscopic  examination. 
The  Thoma-Zeiss  chamber  is  used. 


GENERAL     SURGICAL     CONSIDERATIONS 


35 


Counting  Erythrocytes. 

The  pipette  is  then  twirled  again  so  as  to  make  certain  that 
there  is  a  uniform  distribution  of  the  corpuscles  and  a  few  drops  are 
blown  out  (the  part  which  has  not  been  in  the  bulb  contains  mostly  salt 
solution  and  few  corpuscles).  A  drop  is  then  placed  on  the  platform  of 
the  counter  and  is  covered  with  one  of  the  specially  ground  glasses  which 
go  with  the  instrument.  This  step  requires  care.  There  must  be  no  air 
bubbles ;  the  entire  platform  should  be  covered  and  none  of  the  liquids 
should  run  into  the  moat.  If  these  requirements  are  not  fulfilled,  remove 
the  cover-glass,  clean  the  chamber  and  use  a  new  drop.  When  the  satis- 
factory drop  is  obtained,  allow  the  corpuscles  to  settle  and  examine  with 
the  low  power  of  the  microscope.  Be  sure  that  the  corpuscles  are  evenly 
distributed. 

The  following  is  a  quick  and  fairly  accurate  method  of  determining  the 
number  of  erythocytes.  Altogether  80  (5x16)  small  squares  are  counted. 
To  the  total  number  of  cells  counted  four  ciphers  are  added  and  the  result 
gives  the  number  of  cells  in  a  cubic  mm.  In  counting  little  squares,  all  the 
cells  touching  the  right  hand  and  upper  boundaries  of  the  square  are  included 
in  count. 


3 

45-4 

f 

J-         S          4 

1 

4          T         5- 

S 

7         i.        ^ 

5" 

74« 

Counting  the  Leucocytes. 

The  drop  is  prepared  according  to  the  same  procedure,  the 
same  precautions  being  used.  The  cells  in  the  entire  field  of  400  squares 
are  counted.  The  drop  is  wiped  off  and  the  slide  cleaned  and  this  perform- 
ance repeated.  Three  drops  altogether  are  counted.  The  difference  between 
the  counts  of  the  various  drops  should  not  exceed  8  at  the  utmost.  If  there 
is  a  greater  discrepancy,  faulty  technique  is  to  blame.  Determine  the  leuco- 
cyte count  thus : 

Drop  A — 42. 
Drop  B — 42. 
Drop  C — 46. 


Sum 130  divided  by  3  gives  an  average  of  43-33-     This  multiplied 

by  200  equals  8,666,  the  number  of  leucocytes  in  a  cu.  m. 

Differential  Count. 

Wright's  stain  may  be  used  but  is  only  good  when  fresh. 


36  GENERAL     SURGICAL     CONSIDERATIONS 

A  very  satisfactory  method  is  to  use  Jenner's  stain  and  methylene  blue. 
The  blood  film  is  allowed  to  dry  in  the  air.  Jenner's  stain  is  dropped  on 
the  slide  and  allowed  to  act  for  two  minutes.  This  is  then  washed  off  and 
Loeffler's  blue  is  allowed  to  act  for  two  minutes.  (If  Jenner's  stain  is  fresh 
and  of  full  strength  this  step  is  superfluous).  This  is  then  washed  off  and 
the  smear  is  allowed  to  dry  in  the  air.  It  is  now  ready  for  examination.  A 
drop  of  cedar  oil  is  dropped  on  the  slide  and  the  smear  is  examined  with 
the  oil  immersion  lens. 

Composition  of  Jenner's  Stain. 

Jenner's  stain  is  made  as  follows:  Equal  parts  of  a  1.2  per  cent,  aque- 
ous solution  of  eosin  and  a  I  per  cent,  aqueous  solution  of  methylene  blue  are 
mixed  in  an  open  dish  and  allowed  to  stand  for  24  hours.  The  resulting  pre- 
cipitate— the  eosinate  of  methylene  blue — is  washed  with  water,  collected  on 
a  filter,  dried  at  a  moderate  temperature,  and  finely  powdered.  The  dye 
can  then  be  stored  in  bottles  and  is  perfectly  stable.  For  staining  purposes 
a  0.5  per  cent,  solution  in  absolute  methyl  alcohol  is  employed ;  this  can  be 
used  at  once  and  keeps  indefinitely.  In  preparing  the  dye  first  weigh  out 
requisite  amount  of  eosin  and  methylene  blue.  The  eosin  is  placed  in  a  mor- 
tar or  evaporating  dish  and  rubbed  into  a  paste  with  a  small  amount  of 
water ;  more  water  is  then  added  until  all  the  dye  is  well  dissolved.  This 
solution  is  poured  into  a  large  saucepan  and  diluted  to  the  proper  point. 
The  methylene  blue  is  now  similarly  brought  into  solution,  though  with  a 
little  more  difficulty  as  the  dye  is  inclined  to  be  lumpy ;  it  must  all  be  dis- 
solved. This  solution  is  poured  directly  into  the  eosin  solution  and  the 
requisite  amount  further  added.  The  mixture  is  stirred  with  a  rod  and 
left  to  stand.  If  the  proper  quantities  have  been  used  and  well  dissolved, 
the  filtrate  is  but  little  colored,  in  which  case  not  much  washing  is  neces- 
sary; if,  however,  there  is  a  distinct  excess  of  either  dye,  and  notably  the 
methylene  blue,  this  must  be  washed  out,  which  is  best  done  by  decantation. 
The  alcoholic  solution  finally  is  prepared  by  rubbing  up  the  dye  with  the 
alcohol  in  a  porcelain  dish.  Absolute  methyl  alcohol  must  be  used. 

The  red  corpuscles  are  stained  a  terra  cotta,  the  nuclei  of  leucocytes  and 
nucleated  red  cells  blue,  the  plaques  mauve,  the  neutrophilic  granules  a 
purplish  red,  the  eosinophilic  granules  bright  red,  and  the  mast-cell  gran- 
ules dark  violet.  Granular  degeneration  and  polychromasia  of  the  red  cells 
is  well  shown.  Malarial  organisms,  bacteria  and  filaricie  are  stained  blue. 

Differential  Count. 

For  this  purpose  the  carefully  stained  specimen  is  used.  The 
oil  immersion  lens  is  used  and  the  slide  is  moved  about  by  means  of  a 
mechanical  stage.  For  ordinary  purposes  a  count  of  a  hundred  white  cells 
suffices.  If  the  relative  percentages  of  the  various  kinds  of  white  cells  differ 
from  the  normal  for  the  sake  of  accuracy  it  is  well  to  count  between  300  and 
500.  As  the  cells  are  counted  they  are  accorded  as  shown. 

A  most  important  point  is  to  use  absolutely  clean,  dry  apparatus.  The 
pipettes  after  using  may  be  cleaned  by  sucking  into  them,  in  order,  \vater, 
alcohol  and  ether.  In  case  a  clot  forms  in  the  pipette  nitric  acid  may  be 
sucked  up,  but  especial  care  must  be  used  to  clean  the  pipette  thoroughly 
afterwards  in  the  manner  described  as  a  slight  trace  of  nitric  acid  in  the 
pipette  coagulates  the  blood. 

The  color  index  is  obtained  by  dividing  the  percentage  of  hemoglobin 


GENERAL    SURGICAL     CONSIDERATIONS 


37 


by  the  percentage  of  red  cells,  counting  5,000,000  as  100  per  cent.  Thus  in  a 
given  case,  e.  g.,  the  hemoglobin  is  80  per  cent,  the  red  cells  4,200,000  (84 
per  cent.) 

4,200,000  80 

-  X  100=84.     The  color  index  =     -  .95. 
5,000,000  84 


SPECIFIC  GRAVITY  OF  THE  BLOOD. 

Clinically  the  determination  of  the  sp.  gr.  adds  nothing  of  significance 
to  the  facts  learned  by  the  microscopical  examination  and  the  hemoglobin 
test. 

Hammerschlag's  Method. 

A  clear  glass  cylinder,  measuring  about  ten  centimeters  in 
height,  is  partly  filled  with  a  mixture  of  chloroform  (sp.  gr..  1.526)  and 
benzol  (sp.  gr.,  0.889)  having  a  sp.  gr.  of  1.050  to  1.060.  Into  this  solution 


38  GENERAL  SURGICAL  CONSIDERATIONS 

a  drop  of  blood  is  allowed  to  fall  from  the  ear,  care  being  taken  that  it 
does  not  drop  against  the  side  of  the  vessel.  If  the  drop  sinks  to  the  bot- 
tom, choloroform  is  added  drop  by  drop  and  the  mixture  is  stirred.  If  the 
drop  tends  towards  the  surface  it  is  best  to  add  an  amount  of  benzol  suf- 
ficent  to  cause  the  blood  to  sink  and  then  bring  it  to  the  proper  degre  of 
suspension  by  adding  choloroform.  As  soon  as  the  drop  remains  suspended 
the  mixture  is  filtered  and  its  sp.  gr.  taken  with  an  aerometer.  The  figure 
obtained  is  the  sp.  gr.  of  the  blood.  The  chloroform-benzol  mixture  keeps 
indefinitely. 

Coagulability  is  determined  by  means  of  one  of  the  various  coagulo- 
meters  of  which  Wright's  is  the  best.  The  blood  is  allowed  to  stand  in  tubes 
which  are  part  of  the  apparatus  and  these  tubes  are  successively  examined 
at  intervals  of  a  half-minute  until  clotting  has  taken  place,  and  the  time  that 
the  blood  has  stood  until  the  formation  of  the  first  coagulum  is  recorded. 

Widal  test  is  an  aid  in  the  diagnosis  of  typhoid  fever. 

TECHNIQUE  OF  STOMACH   CONTENTS   EXAMINATION. 

Test  Meal. 

The  stomach  tube  is  passed  and  the  stomach  is  thoroughly  washed  out 
with  lukewarm,  sterile  Water.  The  stomach  tube  is  then  removed  and  the 
patient  given  a  test  meal,  consisting  of  two  dry  crackers  and  eight  ounces 
of  tea,  without  sugar  or  cream,  which  is  removed  after  one  hour  by  means 
of  the  stomach  tube. 

The  Stomach  Tube. 

The  stomach  tube  used  is  made  of  a  not  too  soft  grade  of  rubber.  The 
rube  is  about  70  to  75  cm.  long  and  has  several  apertures  at  the  end  which 
enters  the  stomach.  A  mark  is  placed  about  40  cm.  from  the  end  as  a  guide 
as  to  how  far  the  tube  is  to  be  introduced.  For  gastric  lavage  a  rubber  or 
glass  funnel  is  attached  to  the  proximal  end.  The  tube  is  boiled  in  water 
before  using  and  is  cleansed  in  hot  water  after  using.  (It  is  best  to  have 
separate  tubes  for  tubercular,  leutic  and  carcinomatous  cases.) 

A  great  many  centra-indications  to  the  use  of  a  stomach  tube  have 
been  mentioned,  the  chief  of  which  is  recent  hemorrhage  from  the  stom- 
ach In  nearly  all  other  conditions,  except  possibly  in  advanced  aneurism, 
the  passing  of  the  tube,  with  moderate  care,  is  fraught  with  little  danger. 

Technique  of  Tube  Introduction. 

The  technique  of  passing  the  tube  is  simple.  The  patient  is  asked  to  sit 
up,  the  back  is  firmly  supported,  the  clothing  is  protected  by  a  rubber  bib 
and  sheets.  The  tube  may  be  dipped  in  glycerine,  or  butter  may  be  used 
for  a  lubricant.  The  tube  is  passed  to  the  posterior  wall  of  the  pharynx ;  the 
head  of  the  patient  is  bent  forward  slightly  ;  the  index  fing.er  of  the  left 
hand  may  be  used  to  guide  the  tube  into  the  esophagus.  The  patient  is 
asked  to  take  a  deep  breath  and  then  a  swallow.  This  is  continued,  the 
tube  being  pushed  gently  with  each  act  of  deglutition,  until  (watching  the 
mark)  the  tube  is  seen  to  be  in  the  stomach.  At  no  time  and  under  no 
conditions  should  any  force  be  used.  If  the  patient  becomes  cyanotic  or 
faint  the  tube  is  to  be  instantly  withdrawn. 

If  the  gastric  juice  does  not  flow  the  patient  is  asked  to  cough  and  the 
tube  is  alternately  withdrawn  slightly  and  introduced  (the  end  is  never 


GENERAL    SURGICAL     CONSIDERATIONS  39 

drawn  out  of  the  stomach).  Usually  the  juice  will  flow  after  slightly 
maneuvering.  A  Boas  bulb  or  any  suction  apparatus  (syringe,  etc.)  may  be 
used  to  aspirate  the  fluid.  Always  allow  the  free  end  of  the  tube  to  hang 
well  down,  so  as  to  facilitate  the  flow.  If  no  contents  are  obtained  after 
prolonged  efforts,  introduction  of  a  couple  of  ounces  of  water  will  some- 
times start  the  flow  as  the  tube  may  have  been  clogged,  and  if  this  water 
returns  clear  it  serves  as  evidence  that  the  stomach  is  empty. 
The  tube  should  not  be  withdrawn  too  rapidly. 

Chemical  Tests  for  Gastric  Juice. 

The  reaction  is  tested  with  blue  and  red  litmus  paper.  Acid  turns 
blue  litmus  red  and  red  litmus  turns  blue  in  an  alkaline  medium.  Congo 
red  paper  may  be  used  to  ascertain  whether  free  HC1  is  present  (red  turns 
to  deep  blue). 

The  quantity,  the  appearance,  the  color  and  the  odor  are  noted  and 
tentative  conclusions  are  arrived  at. 

The  stomach  contents  are  filtered,  the  filtrate  being  used  for  chemical  an- 
alysis, the  residue  for  microscopic  examination. 

The  total  acidity  is  first  determined  as  follows : 

Ten  cc.  of  gastric  juice  are  titrated  with  a  decinormal  solution  of 
sodium  hydroxide  (made  by  dissolving  4  gms.  of  NaOH  in  a  liter  of  water) 
i  to  2  drops  of  an  alcoholic  solution  of  phenolphthalein  being  used  as  an 
indicator  until  the  red  color  which  appears  after  the  addition  of  each  drop 
of  NaOH  solution  no  longer  disappears  upon  stirring.  The  number  of 
cc.  of  NaOH  used  is  then  carefully  read  off.  The  acidity  may  be  ex- 
pressed in  one  of  two  ways,  either  in  "acidity  per  cent."  or  "degrees,"  or 
in  actual  percentage.  The  former  being  the  simpler  is  now  more  com- 
monly used;  the  number  of  cc.  is  multiplied  by  ten  (since  only  ten  cc. 
were  used  and  "degrees"  expresses  the  acidity  for  100  cc.)  the  result  is 
the  number  of  degrees  of  total  acidity. 

(Ex.  10  cc.  of  gastric  juice  required  5.8  cc.  of  decinormal  NaOH  to 
neutralize;  the  total  acidity  is  5.8X10,  or  58  degrees.) 

To  find  the  total  acidity  in  actual  percentage,  take  the  number  of  cc. 
used  (in  above  case)  5.8  and  multiply  X  0.00365 — .0212 — this  gives  the 
acidity  in  10  cc.  So  .0212X10  or  .212  equals  the  percentage  of  total  acids 
in  the  gastric  juice.  Expressed  in  degrees  the  normal  total  acidity  is  be- 
tween 45  and  65. 

Free  HCI  (Toepfer  test)  0.5  per  cent,  alcoholic  solution  of  dimethyl- 
amidoazobenzol  is  used.  Two  drops  are  added  to  I  cc.  of  gastric  contents 
(need  not  be  filtered)  ;  in  the  presence  of  free  HCI  a  beautiful  cherry  red 
color  develops,  the  color  being  more  intense  the  more  free  acid  is  present. 
If  no  free  acid  is  present,  a  yellow  turbid  color  results. 

Guenzberg  test — A  solution  is  employed  consisting  of  2  gms.  of  phloro- 
glucin,  i  gm.  vanillin  and  30  cc.  of  absolute  alcohol.  This  decomposes  rap- 
idly and  should  therefore  be  kept  in  a  dark  glass  bottle.  A  few  drops  of 
filtered  gastric  juice  and  an  equal  quantity  of  the  reagent  are  warmed  (not 
boiled)  together  in  a  porcelain  evaporating  dish.  In  the  presence  of  free 
'  HCI  a  series  of  rose  (not  brownish)  lines  develop  around  the  edge.  This 
is  a  positive  test  for  free  HCI,  not  as  delicate  as  Toepfer's  and  more  com- 
plicated. It  is  more  accurate  to  dissolve  4  gms.  of  NaOH  in  less  than  a 
thousand  cc.  and  bring  the  solution  to  the  proper  strength  by  titrating  it 
against  a  solution  of  oxalic  acid  of  standard  strength. 


4O  GENERAL  SURGICAL  CONSIDERATIONS 

Quantitative  Determination  of  Free  HCl. — Ten.  cc.  of  filtered  gastric 
juice  are  titrated  (as  for  total  acidity)  with  decinormal  NaOH  solution, 
using  2  to  3  gtts.  of  0.5  per  cent  alcoholic  solution  of  dimethylamidoazoben- 
zol  as  an  indicator,  NaOH  solution  is  added  drop  by  drop  and  the  gastric 
juice  stirred,  until  the  red  color  has  entirely  disappeared.  The  reading  is 
determined  and  calculations  made  precisely  as  described  for  total  acidity. 
If  the  amount  of  contents  removed  is  small,  10  cc.  can  be  made  to  do  for 
both  titrations.  The  titration  for  free  acid  is  first  made  with  dimethylamido- 
azobenzol  as  just  described  and  the  reading  taken ;  then  phenolphthalein  is 
added  and  titration  continued  until  the  gastric  juice  assumes  a  pink  hue. 
The  sum  of  the  two  titrations  gives  the  total  acidity.  Normal  25  to  50 
degrees. 

The  combined  acids  may  be  determined  by  using  alizarin  as  an  indicator 
and  titrating  with  decinormal  NaOH  solution  until  a  violet  color  is  obtained. 
The  practical  value  of  this  performance  is  very  doubtful. 

Among  the  above  tests  the  presence  or  absence  of  free  HCl  is  the  most 
important ;  more  so  than  the  percentage  of  total  acids  or  free  acids.  In  the 
presence  of  HCl,  organic  acids  may  be  disregarded.  Pepsin,  too,  may  be 
omitted,  for  it  is  always  present  when  free  HCl  is  present. 

Pepsin  and  Pepsinogen — If  free  HCl  is  present  in  gastric  juice,  to  test 
for  pepsin  is  superfluous.  Should  free  HCl,  however,  be  absent  and  it  is 
desired  to  know  whether  pepsin  be  present  or  not,  proceed  as  follows :  To 
25  cc.  of  filtered  gastric  juice  add  3  to  5  gtts.  of  HCl.  Then  0.05  gms.  of 
egg  albumin  is  added  and  this  is  kept  at  a  temperature  of  37  to  40  degrees  C. 
The  egg  albumin  should  be  digested  within  three  hours. 

The  simplest  but  not  quite  the  most  accurate  method  of  determining 
the  quantity  of  pepsin  is  by  the  Hammerschlag  method.  He  used  a  I  per 
cent,  solution  of  albumin  with  0.4  per  cent,  free  HCl  which  he  put  into  two 
tubes,  10  cc.  in  each.  To  A  is  added  5  per  cent,  of  water ;  to  B,  5  cc.  of  gas- 
tric juice.  These  are  left  in  a  thermostat  for  about  two  hours.  The  albumin 
in  each  is  then  tested  with  Esbach's  reagent  in  an  Esbach  tube. 

Rennet  may  be  tested  for  by  Riegel's  method,  5-10  cc.  of  gastric  juice 
neutralized  with  decinormal  NaOH  and  5-10  cc.  of  fresh  milk.  This  mix- 
ture is  placed  in  a  thermostat.  Normally  this  will  coagulate  in  from  10  to 
15  minutes.  Lactic  acid  must  be  excluded  and  the  reaction  should  be  un- 
changed by  the  ferment. 

Lactic  Add. — Lactic  acid  is  seldom  found  if  the  stomach  has  been 
washed  out  and  a  test  meal  given  and  removed  after  one  hour,  for  lactic 
acid  is  not  formed  in  this  length  of  time.  It  is  well  to  test  for  it  in  the  fast- 
ing stomach.  In  all  cases  it  is  well  to  exclude  possibility  of  lactic  acid  hav- 
ing been  ingested. 

The  best  test  for  lactic  acid  is  Ueffelmann's.  Always  make  reagent 
fresh.  To  about  20  cc.  of  I  per  cent,  acid  in  a  test  tube  is  added  I  drop  of 
10  per  cent,  ferric-chloride.  A  deep  amethyst  color  results.  This  is  diluted 
with  water  until  the  solution  is  pale  amethyst.  Divide  into  two  equal  parts. 
To  one  part  add  a  drop  of  distilled  water  (as  a  control)  ;  to  the  other,  add 
a  drop  of  gastric  juice.  If  lactic  acid  is  present,  the  first  fluid  turns  yellow- 
green,  or  "canary"  color. 

Fatty  acids  do  not  normally  occur,  unless  much  milk  or  carbohydrate 
food  has  been  ingested.  Often  they  are  found  in  connection  with  lactic 
acid,  e.  g.,  in  carcinoma  cases.  The  most  frequent  are  butyric  and  acetic. 
They  can  usually  be  detected,  if  present  in  any  quantity,  by  the  sense  of 


GENERAL    SURGICAL     CONSIDERATIONS  41 

smell.  The  simplest  is  the  "pineapple"  test.  10  cc.  of  filtered  gastric  juice 
are  extracted  with  50  cc.  of  ether.  Ether  is  evaporated — a  little  sulphuric 
acid  and  alcohol  is  added  to  the  residue.  Butyl  ethylate  is  formed  which 
smells  like  pineapple. 

Acetic  acid  may  be  detected  by  the  odor  or  by  extracting  10  cc. 
of  gastric  juice  (filtered)  with  ether.  Evaporate;  the  residue  is  dissolved 
in  a  few  drops  of  water  and  accurately  neutralized  with  a  dilute  solution 
of  NaOH.  Sodium  acetate  is  in  this  way  formed.  To  this  a  drop  or  two  of  di- 
lute ferric  chloride  is  added.  A  dark  red  color  indicates  presence  of  acetic 
acid. 

With  silver  nitrate  a  precipitate  is  obtained  which  dissolves  in  hot 
water. 

Mucus  may  be  seen,  when  present  in  any  quantity,  with  the  naked 
eye.  If  equal  parts  of  lime  water  and  diluted  acetic  acid  be  shaken  up  with 
5  cc.  of  gastric  juice,  a  gelatinous  cloud  forms  if  mucus  be  present. 

Bile  is  tested  for,  by  Gmelin's  test.  A  few  cc.  of  fuming  nitric  acid 
is  poured  into  a  test  tube  and  about  10  drops  of  filtered  gastric  juice  are 
superimposed.  In  presence  of  bile  a  play  of  color  is  seen  (on  standing)  at 
or  slightly  above  the  line  of  contact. 

The  presence  of  blood,  as  of  bile,  may  be  svispected  by  the  color  of  the 
contents.  Deen's  test  is  reliable.  To  the  gastric  juice  is  added  I  cc.  of  fresh 
tincture  of  guaiac  and  i  cc.  of  Huehnerfeld's  solution  (glacial  acetic  acid, 
i,  distilled  water,  i,  oil  of  turpentine,  100  and  alcohol,  100).  This  mixture 
is  shaken.  If  blood  is  present  the  fluid  turns  blue.  (Certain  iron  com- 
pounds and  some  vegetables,  etc.,  also  give  this  reaction,  so  it  is  chiefly  of 
negative  value. 

Microscopical  Examination. — Slides  are  prepared  from  the  residue  of 
the  gastric  juice.  They  should  not  be  too  thickly  spread.  They  may  be 
stained  with  methylene  blue  or  any  of  the  ordinary  stains.  Examination 
should  be  made  especially  for  Oppler-Boas  bacilli,  sarcinse  ventriculi,  and 
fragments  of  mucous  membrane  or  neoplasms,  blood  or  pus.  Tubercle 
bacilli  should  be  looked  for  in  suspicious  cases  after  staining  by  the  usual 
Ziehl-Gabbet  method. 

Ziehl's  solution — Carbol  f uchsin :  Saturated  alcoholic  solution  of  fu- 
chsin,  10  cc. ;  5  per  cent,  carbolic  acid  water,  90  cc. 

Gabet's  methylene-blue — Methylene  blue,  2 ;  sulphuric  acid,  25  ;  wa- 
ter, 75. 

GENERAL  PREPARATIONS. 

In  this  systematic  examination  many  things  are  considered  which  may 
not  have  any  bearing  upon  any  given  case  in  question,  but  when  applied  to 
all  the  cases  in  practice  each  point  is  of  more  or  less  importance. 

Of  course,  the  systematic  analysis  of  cases  must  not  be  supposed  to 
render  superfluous  the  judgment  and  practical  experience  of  the  surgeon 
or  physician  who  makes  the  examination.  A  thorough  system,  good  judg- 
ment, and  a  wide  experience  will  result  in  the  accomplishment  of  benefit 
to  the  patient  when  employed  simultaneously. 

After  all  of  the  circumstances  present  in  the  case  have  been  determined 
the  necessary  preparations  for  the  operation  may  proceed. 

Concomitant  Diseases. 

If  there  exists  serious  disease  of  one  of  the  important  organs,  aside  from 


42  GENERAL  SURGICAL  CONSIDERATIONS 

the  condition  to  be  relieved  by  the  operation,  i.  e.,  if  the  bloodvessels,  heart, 
lungs,  kidneys,  liver,  pancreas  or  spleen,  or  the  blood  be  seriously  im- 
paired, it  is  well  to  overcome  this  fault  unless  it  is  directly  the  result 
of  a  condition  which  is  to  be  relieved  by  the  operation  itself  and  will  prob- 
ably improve  much  more  rapidly  after  than  before  the  operation.  This  is 
especially  true  in  patients  suffering-  from  anemia.  If  such  anemia  depends 
upon  a  loss  of  blood  which  will  be  stopped  by  the  operation,  then  the 
recovery  will  usually  be  exceedingly  rapid  after  the  operation  has  been 
performed ;  if  due  to  other  causes  the  patient's  recovery  will  be  very  slow 
unless  the  anemia  is  relieved  before  the  operation  is  done.  If  no  important 
organ  is  seriously  impaired  it  is  much  better  not  to  worry  the  patient  un- 
necessarily before  the  operation.  As  a  rule,  long-continued  preparatory 
treatment  leaves  the  patient  in  a  much  less  favorable  condition  for  a 
surgical  procedure  than  a  very  short  and  simple  preparation  which  serves 
to  put  the  kidneys,  the  skin  and  the  alimentary  canal  in  a  state  favorable  to 
the  elimination  of  the  waste  products. 

The  Day  Before  Operation. 

During  the  day  before  the  operation  the  patient  should  be  kept  on 
light  diet,  consisting  of  sterilized  food,  preferably  broth  or  gruel,  and  al- 
lowed an  abundance  of  good  water,  preferably  hot,  in  order  to  favor  elim- 
ination through  the  kidneys.  A  non-irritating  cathartic  should  be  given 
and,  if  possible,  a  warm  bath.  For  several  years  we  have  given,  as  a  rule, 
two  ounces  of  castor  oil  in  the  foam  of  beer  or  malt  extract  the  day  before 
an  operation,  and  a  large  soap  and  water  enema,  or  one  consisting  of  nor- 
mal salt  solution,  on  the  morning  of,  or  on  the  evening  before  the  opera- 
tion. In  this  manner  the  patient  is  relieved  in  a  relatively  short  time  of 
much  waste  matter  and  is  consequently  removed  from  the  likelihood  of 
absorbing  the  products  of  decomposition  which  may  be  present  in  the  ali- 
mentary tract.  We  have  found  that  so  large  a  close  of  castor  oil  is  borne  per- 
fectly by  almost  all  patients,  and  that  it  does  not  give  rise  to  disturbance, 
pain  or  exhaustion.  We  have  also  found  that  foam  of  beer  or  malt  extract 
disguises  the  oil  so  thoroughly  that  those  who  are  ordinarily  nauseated  very 
readily  will  bear  this  method  without  annoyance. 
Prolonged  Preparatory  Treatment  Condemned. 

In  the  vast  majority  of  patients  this  amount  of  preparation  suffices  to 
relieve  the  body  of  any  burden  it  may  possess  which  might  interfere  with 
the  progress  of  healing,  or  the  normal  course  of  convalescence.  In  other 
words,  the  patient  approaches  the  operation  in  a  comparatively  clean  con- 
dition ;  his  strength  has  not  been  impaired  by  confinement  and  his  nervous 
system  has  not  suffered  by  looking  forward  to  the  operation  for  a  long  time. 
Some  years  ago  we  had  the  opportunity  to  observe  the  effect  of  waiting  for 
a  number  of  days,  and  sometimes  for  several  weeks,  to  allow  the  patient 
to  get  into  a  more  favorable  condition  for  operation,  and  \ve  are  positive  that 
as  a  rule  the  practice  is  bad.  The  exceptions  are  in  those  patients  in  whom 
the  heart,  the  kidneys  or  the  blood  are  too  seriously  impaired,  and  who 
might  be  placed- in  a  better  state  by  waiting:  and  in  cases  in  which  infec- 
tion is  present  which  may  become  circumscribed  or  may  be  eliminated. 

We  will  refer  to  these  conditions  again  in  connection  with  patients  in 
whom  they  are  present;  and  will  especially  refer  again  to  old  age,  because 
elderly  patients  bear  many  operation?  remarkably  well  if  they  are  not  con- 


GENERAL     SURGICAL     CONSIDERATIONS  43 

fined  before,  and  only  for  a  short  time  after,  the  operation,  while  quite  the 
opposite  is  true  if  this  precaution  is  overlooked. 

THE  FIELD  OF  OPERATION. 

Immediate  Preparation  Sufficient. 

In  hospitals  where  many  operations  are  performed  on  the  same  day, 
so  that  the  time  spent  over  each  case,  immediately  preceding  an  operation,  is 
of  importance,  it  may  be  well  to  prepare  the  field  of  operation  on  the  day 
before,  but  this  is  done  simply  as  a  convenience,  and  not  because  it  is  better 
than  it  would  be  to  prepare  the  field  of  operation  immediately  before  be- 
ginning- to  operate.  For  months  at  a  time  we  have  followed  the  latter  plan 
without  having  a  single  wound  infected,  and  other  surgeons  have  had  the 
same  experience,  hence  there  can  be  no  good  reason  for  insisting  upon 
having  the  field  of  operation  prepared  one  or  more  days  before  the  opera- 
tion. However,  this  may  be  done  as  a  matter  of  convenience. 

Details  of  Surface  Preparation. 

The  important  point  in  preparing  a  surface  for  operation  lies  in  thor- 
ough washing  with  soap  and  water;  anything  that  is  accomplished  beyond 
this  is  of  little  importance,  provided  the  washing  process  has  been  done 
carefully  and  thoroughly.  In  our  practice  the  steps  taken  in  preparing  the 
field  of  operation  are  as  follows:  i,  Thorough  scrubbing  Avith  soft  soap 
and  warm  water  with  a  moderately  stiff  brush ;  2,  Washing  the  surface  with 
a  piece  of  aseptic  gauze  saturated  with  fresh  water,  because  the  epithelial 
scales  which  have  been  loosened  with  the  brush  are  easily  removed  in  this 
manner ;  3,  Soaping  and  shaving  the  field  of  operation ;  4,  Washing  again 
with  aseptic  gauze  and  sterile  water ;  5,  Washing  the  surface  with  com- 
mercial, i.  c.,  about  ninety-five  per  cent.,  alcohol ;  6,  Washing  with  a  so- 
lution of  corrosive  sublimate,  one  part  in  two  thousand. 

In  many  cases  only  the  first  four,  or  the  first  five  steps  were  taken 
and  always  with  the  same  results,  consequently  we  are  confident  that  care- 
ful washing  of  the  surface  with  soap  and  water  is  the  important  part,  but 
as  there  can  be  no  harm  in  the  other  two  procedures  they  might  as  well 
be  taken,  so  long  as  it  is  convenient  in  any  given  case. 

Use  of  Antiseptic  Fluids. 

There  is  still  a  distinct  superstition  in  favor  of  the  use  of  some  anti- 
septic fluid  for  washing  the  field  of  operation,  and  so  long  as  the  fluid 
employed  is  harmless  we  believe  that  we  are  justified  in  using  it.  If  this 
preparation  is  made  just  before  beginning  the  operation  it  will  suffice,  if 
made  on  the  day  before  the  operation  the  surface  must  be  protected  against 
re-infection  during  the  interval ;  this  can  be  done  by  applying  sterile  gauze 
or  cotton  to  the  surface,  holding  it  in  place  by  means  of  a  carefully  applied 
bandage.  On  the  following  day  the  surface  is  once  more  washed  with  a 
piece  of  sterile  gauze  saturated  with  alcohol  and  is  then  ready  for  opera- 
tion. 

Avoid  Skin  Irritation. 

It  is  important  not  to  irritate  the  skin  by  the  violent  use  of  a  stiff 
brush  or  the  careless  use  of  the  razor,  and  care  should  be  taken  to  have  the 
razor  sterilized.  It  is  an  easy  matter  to  irritate  the  skin  during  vigorous  or 
violent  preparation  to  such  an  extent  that  the  microorganisms  normally 


44  GENERAL  SURGICAL  CONSIDERATIONS 

contained  therein  will  be  forced  into  activity,  making-  at  least  a  slight  in- 
fection certain  to  occur. 

It  is  much  better  simply  to  wash  the  field  of  operation  very  gently  with 
soap  and  warm  water  with  a  soft  piece  of  gauze  than  to  use  any  method, 
however  thorough  it  may  seem,  which  will  leave  the  skin  in  an  irritated  con- 
dition. 

Sterile  Towels  About  the  Wound. 

In  order  to  prevent  infection  of  the  field  of  operation  from  any  of  the 
adjacent  surfaces,  it  is  well  to  lay  four  sterile  towels  around  the  part  and 
hold  them  in  place  by  means  of  safety  pins,  or  better  still  by  the  use  of  for- 
ceps with  sharp  beetle-like  mouths  which  will  grasp  the  towels,  together 
with  a  little  of  the  underlying  skin,  and  will  thus  prevent  slipping  of  the 
towels.  The  space  exposed  should  be  large  enough  so  that  the  towels  need 
not  be  shifted  during  the  operation,  because  such  an  act  is  likely  to  cause 
infection  by  carrying  micro-organisms  on  the  under  surface  of  the  towel 
from  adjacent  portions  to  the  field  of  operation.  During  the  operation  these 
towels  should  be  left  in  place,  and  in  case  they  have  become  soiled  they 
should  be  covered  with  fresh  towels,  but  otherwise  they  should  not  be  dis- 
turbed or  removed.  Again,  when  the  operation  has  been  completed  the 
greatest  care  should  be  exercised  to  protect  the  wound  while  these  towels 
are  removed.  This  can  be  done  very  easily  by  placing  a  piece  of  moist,  asep- 
tic gauze  over  the  entire  surface  of  the  wound  and  leaving  it  in  place  until 
all  the  necessary  disturbance  has  been  completed,  then  carefully  sponging 
the  surfaces  around  this  pad,  and  at  last  removing  the  pad  and  covering 
the  wound  with  proper  dressings. 

Avoid  Infection  from  Surrounding  Parts. 

During  the  operation  it  is  best  to  handle  the  tissues  as  little  as  possi- 
ble, and  to  do  this  with  instruments  as  much  as  may  be,  and  as  little  as 
possible  with  the  hands,  and  never  to  manipulate  the  patient's  skin  first 
and  then  the  wound,  because  the  epidermis  almost  always  contains  some 
micro-organisms  which  might  be  transferred  to  the  wound. 

A  practice  which  should  be  guarded  against  consists  in  first  sponging 
all  about  the  wound  and  finally  the  wound  itself.     If  the  skin  about  the 
wound  be  sponged  at  all,  the  same  sponge  should  not  be  used  in  or  upon 
the  wound  thereafter. 
Tincture  of  Iodine  in  Crushed  Wounds. 

Recently  a  method  of  disinfection  of  the  field  of  operation  with  tincture 
of  iodine  has  been  recommended  by  Grossich,  which  has  the  excellent 
qualities  of  being  simple,  convenient,  safe,  efficient  and  generally  applicable. 
The  method  has  been  further  developed  and  perfected  by  Bogdan,  whose 
plan  is  worthy  of  adoption,  especially  in  cases  which  have  sustained  severe 
crushing  injuries  in  which  the  method  described  above  is  not  altogether 
satisfactory  because  -in  scrubbing  the  areas  surrounding  the  wound  much 
of  the  dirt  is  certain  to  drain  into  the  wound  during  the  process  of  disinfec- 
tion, and  it  is  questionable  whether  the  harm  which  will  be  done  by  this 
soiling  of  the  wound  is  not  greater  than  the  benefit  derived  from  the  dis- 
infection. 
Iodine  and  Benzine. 

Rogdan's  method  consists  in  making  a  solution  of  one  part  of  iodine 


GENERAL     SURGICAL     CONSIDERATIONS  45 

crystals  in  one  thousand  parts  of  benzine,  which  can  be  readily  accomplished 
by  adding  one  drachm  of  iodine  crystals  to  the  gallon  of  benzine  or  one 
gram  to  the  litre. 

The  entire  area  to  be  disinfected  is  carefully  shaved  dry  in  case  the 
portion  of  the  body  is  covered  with  a  perceptible  growth  of  hair,  it  is  then 
rubbed  off  carefully  with  pledgets  of  sterile  gauze  saturated  with  this  fluid. 
This  is  repeated  several  times,  the  disinfection  of  a  large  area  consuming 
not  more  than  two  or  three  minutes.  When  the  benzine  has  evaporated 
the  entire  surface  is  painted  repeatedly  with  tincture  of  iodine,  also  for  a 
period  of  about  two  minutes,  pledgets  of  sterile  cotton  being  used  for  this 
purpose.  As  soon  as  the  alcohol  contained  in  the  tincture  of  iodine  has 
evaporated,  leaving  the  area  perfectly  dry,  the  operation  may  begin.  This 
method  has  proven  most  satisfactory  and  may  be  employed  as  well  in  other 
than  traumatic  cases,  although  in  non-traumatic  cases  there  is  not  the  same 
necessity  to  vary  from  the  method  described  at  the  beginning  of  this  sec- 
tion. 

Caution  in  Use. 

In  these  cases  the  patient  should  be  given  a  thorough  soap  and  warm 
water  bath  on  the  day  before  the  operation,  and  the  operative  area  should 
be  soaped  and  shaved  and  again  washed  with  warm  water  in  order  to  re- 
duce the  time  necessary  for  preparation  on  the  day  of  operation,  when  the 
remaining  steps  in  the  process  of  disinfection  described  above  should  be 
carried  out.  It  is  important  to  bear  in  mind  that  the  use  of  benzine  is  ex- 
tremely dangerous  in  the  presence  of  gas-light  or  fire  of  any  kind,  conse- 
quently, in  preparing  the  field  of  operation,  quite  as  much  care  should  be 
taken  when  this  method  is  employed  as  when  ether  is  used. 

As  this  is  always  undertaken  by  thoroughly  trained  nurses  or  physi- 
cians, the  danger  is  not  really  very  great  in  case  their  attention  is  directed 
to  this  factor. 

PREPARATION  OF  THE  HANDS. 

What  has  been  said  concerning  the  preparation  of  the  field  of  operation 
applies  very  closely  to  the  care  of  the  operator's  hands  before  an  operation. 

Details  of  Hand  Disinfection. 

The  important  point  is  to  make  sure  of  careful,  thorough  washing 
with  soap  and  sterile  water,  then  cleansing  the  space  underneath  the  finger 
nails,  then  washing  again,  first  with  a  moderately  soft  brush  and  then  with 
a  piece  of  gauze.  \Ye  have  found  it  an  advantage  to  wash  in  a  deep  basin 
full  of  \varm,  sterile  water,  keeping  the  hands  under  water  while  scrubbing 
with  the  brush  and  washing  with  the  gauze  pad,  and  then  to  wash  in  sterile 
running  water  after  the  hands  have  been  thoroughly  scrubbed  underneath 
the  soap  suds. 

Smooth  Skin. 

It  is  important  above  all  things  to  keep  the  skin  upon  the  hands  smooth 
and  soft,  and  not  covered  with  grooves  and  crevices.  If  the  surgeon's  skin 
is  smooth  it  is  much  easier  to  keep  the  hands  aseptic  than  if  it  has  been 
roughened  by  the  use  of  strong  antiseptic  solutions.  There  is  a  great  dif- 
ference in  the  skin  of  the  hands  of  different  surgeons,  and  consequently  it 
is  wise  for  each  one  to  avoid  the  antiseptic  solution  which  happens  to  be 


46  GENERAL    SURGICAL     CONSIDERATIONS 

harmful  in  his  case ;  and  if  all  solutions  have  the  same  effect,  it  is  wise  sim- 
ply to  wash  with  soap  and  sterilized  water,  because  smooth  hands  can 
be  rendered  perfectly  safe  in  this  way,  while  rough  hands  cannot  be  made 
safe  by  the  additional  use  of  any  one  of  the  various  antiseptic  solutions 
which  have  been  recommended. 

Even  the  employment  of  certain  varieties  of  soap  has  a  ruinous  effect 
upon  the  hands  of  some  surgeons,  but  with  them  it  is  always  possible  to  de- 
termine experimentally  what  variety  of  soap  has  this  harmful  effect  and  by 
changing-  the  ingredients  so  as  to  neutralize  the  substance  which  gives  rise 
to  the  irritation  it  is  practically  always  possible  to  overcome  this  difficulty. 
Should  the  hands,  however,  become  roughened  notwithstanding  the  exercise 
of  all  of  these  precautions  this  can  usually  be  overcome  readily  by  syste- 
matically caring  for  the  hands  at  the  end  of  the  day  in  order  that  during 
the  night's  rest  the  skin  may  recover  from  the  day's  irritation. 

To  Overcome  Roughness  of  the  Hands. 

The  hands  in  these  cases  should  be  washed  before  retiring  with  a  soft 
cloth  in  a  deep  basin  filled  with  exceedingly  hot  water  to  which  a  sufficient 
amount  of  non-irritating  soap  has  been  added  to  make  it  smoothe,  or  in 
case  all  soap  causes  irritation,  bran  may  be  added  to  the  water.  The  water 
should  be  just  as  hot  .as  can  be  borne  and  the  washing  should  be  continued 
for  several  minutes  until  the  hands  are  thoroughly  hot.  Then  they  should 
be  plunged  into  cold  water,  that  is,  having  the  ordinary  temperature  of  the 
water  supply  in  most  cities.  After  a  minute  the  hands  are  to  be  dried  and 
anointed  with  lanoline  and  covered  for  the  night  with  soft  chamois  skin 
gloves.  In  most  instances  this  course  will  entirely  and  speedily  overcome 
the  roughness  of  the  skin. 

In  our  own  practice  we  follow  the  washing  with  soap  and  water  by  the 
use  of  strong  alcohol,  and  then  a  solution  of  corrosive  sublimate,  one  to 
two  thousand. 

Avoid  Pus. 

In  hospital  practice  there  are  certain  other  precautions  which  are  of 
exceedingly  great  importance,  largely  in  the  way  of  prophylaxis,  which 
will  aid  greatly  in  securing  aseptic  conditions.  The  most  important  of 
these  is  to  keep  the  hands  out  of  pus.  In  dressing  suppurating  wounds 
either  forceps  or  rubber  gloves  should  be  used,  so  as  to  prevent  the  hands 
from  touching  pus.  Operations  should  be  performed  early  in  the  morning, 
before  any  one  connected  with  the  wounds  has  done  any  dressings.  Puddling 
in  pus  is  pernicious  practice.  This  fact  should  be  impressed  most  forcibly 
upon  every  one  connected  with  the  work. 

Aseptic  cases  should  always  be  operated  first,  and  later  those  containing 
pus.  In  operations  upon  suppurating  cases  rubber  gloves  are  used  at  the 
present  time,  but  in  former  years,  by  taking  the  precautions  indicated  above, 
practically  no  infections  took  place,  although  no  gloves  were  worn. 

Antiseptic  Conscience. 

The  same  precautions  should  be  taken  in  dressing  the  wounds — no 
suppurating  wounds  being  dressed  until  all  the  clean  wounds  have  been 
finished.  Every  evening  before  retiring  the  surgeon  and  all  the  assistants 
should  scrub  their  hands  with  the  same  care  that  is  employed  in  disinfection 
before  an  operation.  It  is  absolutely  necessary  for  every  one  connected 


GENERAL     SURGICAL     CONSIDERATIONS  47 

with  surgical  work  to  develop  an  antiseptic  conscience,  because  upon  this 
depends  the  condition  of  the  wounds  rather  than  upon  any  special  method. 
It  is  a  comparatively  easy  matter  to  secure  an  aseptic  condition  of  the 
hands  before  the  operation,  but  it  requires  great  vigilance  on  the  part  of 
every  one  associated  with  an  operation  to  maintain  this  condition  through- 
out the  procedure.  Unless  each  has  an  antiseptic  conscience  some  one  is 
likely  to  touch  something  which  is  not  surgically  clean  and  transfer  the 
infectious  ^aterial  with  his  hands  to  the  wound.  In  order  to  become  thor- . 
oughly  impressed  with  the  ease  with  which  this  can  be  accomplished,  every 
surgeon  should  take  a  practical  course  in  a  bacteriological  laboratory  ex- 
tending over  a  number  of  months,  because  the  same  carelessness  which  will 
ruin  a  culture  plate  may  cause  a  wound  infecton/and  one  really  cannot  fully 
appreciate  how  easily  this  occurs  until  after  having  had  the  experience  of 
ruining  a  lot  of  pure  cultures  in  bacteriological  experimentation. 

RUBBER  GLOVES. 

If  a  surgeon  has  not  a  smooth,  pliable  skin,  or  if  for  any  reason  it  seems 
difficult  to  obtain  perfectly  clean  hands  by  washing,  or  if  he  has  recently 
touched  infected  wounds,  or  performed  autopsies,  or  dressed  suppurating 
cases,  it  is  well  to  protect  the  patient  to  be  operated  by  wearing  aseptic  rub- 
ber gloves. 

Objections. 

It  should,  however,  be  borne  in  mind  that  the  surgeon  loses  much  in 
dexterity  in  this  way,  and  being  deprived  of  the  finer  sense  of  touch  his  skill 
is  quite  materially  impaired,  and  in  some  very  delicate  operations  this 
impairment  may  be  sufficient  to  deny  the  patient  the  slight  chance  he  had 
of  surviving  the  operation.  Of  course,  this  would  apply  to  only  a  small 
proportion  of  all  the  patients  operated  upon,  but  it  is  large  enough  to  be 
worthy  of  consideration. 

It  is  quite  different  with  the  hands  of  assistants  and  nurses  connected 
with  operations.  These  can  perform  the  less  delicate  duties  which  are 
entrusted  to  them  as  well  with  gloves  as  with  bare  hands,  and  consequently 
the  additional  safety  which  comes  from  covering  their  hands  with  aseptic 
rubber  gloves  is  of  sufficient  importance  to  recommend  their  use. 

Details  of  Use. 

In  using  gloves  it  is  of  the  greatest  importance  to  disinfect  the  hands 
with  the  same  care  as  when  no  gloves  are  used,  because  a  glove  may  tear 
or  become  punctured  at  any  time  during  an  operation.  In  case  this  hap- 
pens the  glove  should  be  discarded  at  once,  as  a  torn  glove  is  necessarily 
much  more  dangerous  than  no  glove  at  all,  its  warmth  and  moisture  having 
a  tendency  to  loosen  the  epithelium  which  may  contain  pathogenic  micro- 
organisms. 

Confirm  Necessity  for  Gloves. 

It  is  important  for  each  individual  surgeon  to  determine  definitely 
whether  or  not  it  is  possible  for  him  to  absolutely  disinfect  his  hands.  This 
can  be  done  easily  by  taking  scrapings  from  his  fingers,  especially  from  por- 
tions underneath  and  at  the  base  and  sides  of  the  finger  nails.  If  a  sur- 
geon's hands  contain  micro-organisms  after  he  has  disinfected  them,  then  it 
will  not  be  safe  for  him  to  operate  without  wearing  rubber  gloves.  There 


4  GENERAL     SURGICAL     CONSIDERATIONS 

is  such  a  vast  difference  between  the  hands  of  different  surgeons  that  a 
rule  for  the  disinfection  of  the  hands  of  one  cannot  properly  apply  to  others 
without  confirmation  by  carefully  carried  out  bacteriological  tests. 

DISINFECTION   OF  INSTRUMENTS. 

All  instruments,  except  knives,  should  be  boiled  for  half  an  hour  in  a 
solution  of  a  tablespoonful  of  baking  soda  to  the  quart  of  water  before  they 
are  put  away  after  operations,  and  again  before  they  are  used.  The  knives 
are  washed  carefully  with  pads  of  sterilized  cotton,  saturated  with  alcohol 
before  and  after  using. 

DISINFECTION  OF  SILK,  SILKWORM  GUT,  HORSE-HAIR,  DRAINAGE 

TUBES  AND  BRUSHES. 

This  is  accomplished  by  boiling  in  water  for  one  hour,  and  preserva- 
tion in  five  per  cent,  solution  of  carbolic  acid  in  water,  or  in  strong  com- 
mercial alcohol,  until  used. 

Method  of  Preparing  and  Preserving  Catgut. 

Catgut  is  prepared  by  immersing  in  sulphuric  ether  for  one  month, 
then  for  one  month  in  strong,  commercial  alcohol,  in  which  one  grain  of 
corrosive  sublimate  to  the  ounce  has  been  dissolved,  the  solution  being  re- 
newed once  during  this  time.  It  is  then  preserved  indefinitely  in  a  solution 
of  one  part  of  iodoform,  five  parts  of  ether  and  fourteen  parts  of  strong, 
commercial  alcohol.  In  this  solution  catgut  may  be  preserved  with  perfect 
safety  for  many  years  in  jars  which  prevent  the  evaporation  of  the  ether. 
The  loss  of  ether  from  the  jars  which  are  opened  occasionally  for  the  re- 
moval of  catgut  to  be  used  from  day  to  day  may  be  made  good  by  adding 
ether  occasionally  when  it  is  noticed  that  iodoform  is  becoming  precipitated 
at  the  bottom  of  the  vessel. 

It  is  not  necessary  to  be  accurate  concerning  the  amount  of  ether  re- 
placed because  an  excess  in  no  way  injures  the  catgut.  The  entire  substance 
of  the  catgut  becomes  thoroughly  permeated  with  fine  crystals  of  iodoform, 
which  remain  in  the  suture  until  the  last  portion  of  catgut  fibre  has  been 
absorbed.  This  is  a  marked  advantage  over  catgut  saturated  with  iodine 
in  which  no  trace  of  this  antiseptic  can  be  found  two  days  after  the  intro- 
duction of  the  buried  suture.  It  should  never  be  handled  by  any  one  ex- 
cept the  surgeon  and  the  chief  assistant.  This  catgut  will  last  seven  to  ten 
days  in  tissues,  according  to  the  size  used.  It  is  employed  in  all  ligatures, 
both  in  the  peritoneal  cavity  and  elsewhere,  and  for  all  buried  sutures  ex- 
cept in  hernias  and  in  the  suturing  of  bones.  For  these  purposes  a  chromic- 
ized  catgut  is  employed,  which  lasts  from  fifteen  to  thirty  days,  according  to 
size.  This  is  prepared  after  the  following  formula:  The  catgut  is  immersed 
in  ether  for  one  month,  then  in  a  solution  prepared  in  the  following  manner : 

Chromicized  Catgut. 

A.  Chromic    acid    I  part. 

Water   5  parts. 

(  Caref ullly  dissolve. ) 

B.  Take  of  solution   A i   part. 

Glycerine    5  parts. 


GENERAL    SURGICAL     CONSIDERATIONS  49 

Take  solution  B  and  soak  therein  catgut  for  forty-eight  to  ninety-six 
hours,  according  to  resistance  wanted.  Forty-eight  hours  will  resist  ab- 
sorption by  tissue  for  fifteen  days ;  ninety-six  hours  will  resist  for  thirty 
days. 

C.  Take  catgut  out  of  solution  B,  rinse  quickly  in  sterilized  water  to 
free  it  from  solution  B,  stretch  and  rub  quickly  with  a  hard,  sterile  towel  to 
remove  any  of  the  solution  B  which  may  still  be  adhering  to  it,  wind  on 
rods,  or  slides  at  least  three  inches  in  length  and  preserve  indefinitely  in  the 
following  solution : 

D.  Carbolic  acid,   95   per   cent I  part. 

Glycerine    5  parts. 

The  catgut  may  remain  in  this  solution  for  many  months  without  de- 
preciating in  quality,  or  it  may  be  kept  for  an  indefinite  period  of  time  in 
the  same  solution  as  the  ordinary  catgut,  composed  of : 

lodoform    I  part. 

Ether    5  parts. 

Strong  alcohol   14  parts. 

The  jar  containing  the  ether  in  which  the  catgut  is  kept  for  one 
month  should  be  filled  only  about  one-half  with  the  loose  coils  of  catgut  and 
then  it  should  be  filled  with  ether ;  it  should  be  closed  air  tight  and  should 
be  picked  up  every  clay  or  two  and  shaken  in  an  inverted  position  in  order 
to  wash  off  any  substance  which  may  accumulate  upon  the  surface  of  the 
coils.  At  the  end  of  two  weeks  the  ether  should  be  removed  and  fresh 
ether  substituted. 

The  same  precautions  should  be  taken  with  the  solution  of  corrosive 
sublimate  in  alcohol. 

It  is  especially  important  not  to  wind  the  catgut  tightly  before  placing 
it  in  these  solutions,  because  this  may  prevent  the  solutions  from  penetrating 
'all  parts  of  the  material. 

One  precaution  is  necessary  in  the  employment  of  catgut  which  has 
been  prepared  in  this  manner ;  it  must  not  be  placed  in  water  before  it  is 
used  at  the  time  of  the  operation. 

It  seems  that  the  iodine  which  is  absorbed  by  the  catgut  in  the  iodo- 
form-ether-alcohol  solution  makes  it  slightly  antiseptic,  which  is  probably 
an  advantage. 

Upon  splitting  a  piece  of  catgut  which  has  been  preserved  in  this  fluid 
and  permitting  it  to  dry  it  will  be  found  that  the  entire  substance  is  per- 
meated with  fine  crystals  of  iodoform  which  will  be  absorbed  no  more  rap- 
idly than  the  catgut  itself,  thus  making  the  latter  slightly  aseptic  until  it  is 
entirely  absorbed. 

This  seems  to  be  of  importance  especially  in  the  use  of  chromic  gut 
because  of  the  length  of  time  it  normally  remains  in  the  tissues. 

These  two  methods  are  so  simple  that  they  can  be  carried  out  as  well 
in  the  simplest  office  of  the  country  practitioner  as  in  the  laboratory  of  a 
well-organized  hospital. 
Experience  Results. 

\Ye  have  personally  used  catgut  prepared  in  this  manner  in  more  than 
twenty  thousand  operations,  and  the  fact  that  we  have  adhered  to  this  method 
of  preparation,  while  we  have  changed  almost  every  other  detail  in  antiseptic 


5O  GENERAL     SURGICAL     CONSIDERATIONS 

technique  in  the  meantime,  shows  that  this  very  simple  method  must  be 
satisfactory. 

Catgut  Infection. 

Observations  have  convinced  us  that  what  is  ordinarily  known  and 
feared  as  catgut  infection  is  quite  unnecessary  and  that  it  depends  upon  one 
or  more  of  five  conditions  which  can  easily  be  eliminated,  viz.:  I,  Com- 
mercial catgut  which  may  not  be  reliable ;  2,  Catgut  that  has  been  saturated 
with  antiseptic  substances  which  cause  a  necrosis  of  the  tissues  included  in 
the  suture  or  ligature ;  3,  Pressure  necrosis  due  to  tying  the  stitches  too 
tightly ;  4,  Infection  of  the  catgut  by  careless  manipulation  by  the  surgeon 
or  his  assistants,  the  suture  or  ligature  being  permitted  to  touch  objects  not 
sterile ;  5,  Infection  of  the  catgut  by  the  septic  hands  of  the  surgeon  or  his 
assistants. 

Although  drawing  sutures  or  ligatures  tightly  enough  to  cause  pres- 
sure necrosis  cannot  produce  infection  by  itself,  this  is,  nevertheless,  a 
very  common,  if  not  the  most  common,  cause  of  what  is  termed  "catgut 
infection,"  inasmuch  as  this  furnishes  a  very  favorable  culture  medium  for 
any  accidental  infection  which  may  occur  during  the  operation  and  which 
would  not  develop  into  suppuration  were  not  the  tissues  impaired  by  the 
constriction  due  to  the  undue  tension  placed  upon  the  stitches  or  ligatures. 

It  has  seemed  to  us  that  much  of  the  improvement  in  aseptic  results 
which  many  surgeons  have  attributed  in  their  practice  to  the  use  of  rubber 
gloves  must  be  due  to  the  fact  that  the  wearing  of  gloves  which  have  an 
exceedingly  smooth  surface  has  prevented  them  from  tying  their  stitches 
and  ligatures  too  tightly  and  that  this  explains  the  decrease  in  the  amount 
of  catgut  infection  in  their  experience. 

This  point  is  so  important  that  we  shall  refer  to  it  again  in  connection 
with  the  various  operations  in  which  its  neglect  is  especially  likely  to  cause 
mischief. 

Importance  of  Safe  Catgut. 

We  have  spoken  at  length  concerning  catgut,  because  if  properly  pre- 
pared and  used  it  is  certainly  an  ideal  suture  and  ligature  material,  and  it  is 
important  to  have  this  material  so  that  it  can  be  invariably  relied  upon. 
Undoubtedly  some  manufacturers  furnish  catgut  in  a  condition  in  which 
it  can  always  be  depended  upon,  but  it  is  difficult  to  ascertain  which  of  these 
firms  are  reliable,  consequently  it  is  best  for  each  surgeon  to  prepare  his  own 
material.  In  large  hospitals  this  can,  of  course,  be  delegated  to  a  depend- 
able person  who  is  permanently  employed  and  who  fully  comprehends  the 
importance  of  his  task.  It  is  not  well  to  assign  assistants  who  frequently 
change  their  service  to  undertake  this  work,  because  then  it  is  impossible 
for  the  surgeon  to  fix  the  responsibility. 

IODINE  CATGUT. 

Catgut  impregnated  with  iodine  has  been  in  use  for  a  number  of  years 
and  has  given  excellent  satisfaction  to  those  who  have  used  it  constantly. 
The  presence  of  this  antiseptic  material  seems  to  increase  the  safety  of  the 
suture  or  ligature  substance  because  it  may  serve  to  destroy  any  micro-or- 
ganisms which  may  have  been  introduced  accidentally  during  the  operation. 
However,  the  especial  value  of  this  method  lies  in  its  simplicity  and  in  the 
fact  that  the  tensile  strength  of  the  catgut  is  but  slightly  impaired  by  the 


GENERAL    SURGICAL     CONSIDERATIONS  51 

process  of  preparation.  The  fact  that  the  iodine  is  entirely  absorbed  long 
before  the  catgut  disappears  makes  this  suture  material  slightly  less  desir- 
able to  use  than  that  prepared  by  the  method  described  above.  It  is,  how- 
ever, possible  to  preserve  this  suture  material  indefinitely  in  the  same  iodo- 
form-ether-alcohol  mixture  that  we  use  for  the  catgut  already  described 
if  the  catgut  is  first  carefully  prepared  by  the  iodine  method,  especially  if 
the  most  excellent  process  invented  by  Willard  Bartlett,  of  St.  Louis,  is 
chosen. 

Willard  Bartlett  Method  of  Preparing. 

In  order  to  secure  uniformly  satisfactory  results  it  is  important  to  carry 
out  the  various  steps  laid  down  in  the  following  description  of  the  method 
with  the  utmost  accuracy,  because  if  any  change  is  made  in  these  steps  the 
catgut  is  likely  to  become  somewhat  hard  or  brittle.  It  is  also  important, 
to  remember  that  the  method  must  never  be  attempted  in  wet  weather  or 
in  a  room  containing  steam  or  moisture. 

"i.  The  strands  are  cut  into  convenient  lengths,  say  thirty  inches, 
and  made  into  little  coils  about  as  large  as  a  silver  quarter.  These  coils 
in  any  desired  number  are  then  strung  like  beads  onto  a  thread  so  that  the 
whole  quantity  can  be  conveniently  handled  by  simply  grasping  the  thread." 

"2.  The  strings  of  catgut  coils  are  dried  for  four  hours  at  the  fol- 
lowing temperatures:  160,  180,  200,  220  degrees,  one  hour  each,  the 
changes  in  temperature  being  gradually  accomplished. 

"3.  The  catgut  is  placed  in  liquid  albolene,  where  it  is  allowed  to  re- 
main until  perfectly  'clear,'  in  the  sense  that  the  term  is  used  in  the  prepara- 
tion of  histological  specimens.  This  is  usually  accomplished  in  a  few  hours, 
though  it  has  been  my  custom  to  allow  the  gut  to  remain  in  the  oil  over 
night. 

"4.  The  vessel  containing  the  oil  is  placed  upon  a  sand  bath  and  the 
temperature  raised  during  one  hour  to  320  degrees  F.,  which  temperature  is 
maintained  for  a  second  hour. 

"5.  By  seizing  the  thread  with  a  sterile  forcep  the  catgut  is  lifted  out 
of  the  oil  and  placed  in  a  mixture  of  iodine  crystals  one  part  in  Columbian 
spirits  (deodorized  methyl  alcohol)  one  thousand  parts.  In  this  fluid  it  is 
stored  permanently,  and  is  ready  for  use  in  twenty-four  hours ;  the  thread 
is  then  cut  and  withdrawn. 

"It  seems  to  me  important  that  the  gut  should  be  thoroughly  'cleared' 
before  the  oil  is  heated,  in  order  that  we  may  thus  be  certain  that  the  tem- 
perature of  the  center  of  the  strand  becomes  as  high  as  that  of  the  oil  out- 
side. It  may  be  noted  further  that  I  do  not  remove  the  oil  from  the  gut 
before  placing  it  in  the  storing  solution.  This  is  done  purposely,  since  cat- 
gut which  is  perfectly  free  from  oil  is  so  very  sensitive  to  the  action  of 
water  that  it  readily  untwists  and  becomes  tangled  after  it  is  used  in  a 
wound  but  a  few  moments.  This  storing  fluid  simply  takes  off  enough  oil 
from  the  exterior  of  the  strand  so  that  it  is  not  too  slippery  for  use,  and 
the  albolene  being  a  bland,  non-irritating  substance,  there  is  no  reason  why 
it  cannot  be  safely  left  in  the  gut.  The  iodine  rapidly  permeates  the 
strand ;  the  same  will  be  found  stained  black  after  a  few  hours,  and  con- 
sequently the  surgeon  will  have  the  assurance  that  he  is  introducing  an  an- 
tiseptic as  well  as  a  thoroughly  sterile  suture  material. 

"As  far  as  the  tensile  strength  and  pliability  of  the  finished  product  are 
concerned,  I  may  state  that  this  leaves  nothing  to  be  desired.  I  have  made 


52  GENERAL    SURGICAL     CONSIDERATIONS 

a  large  number  of  breaking  tests,  and  have  found  no  other  heat  method  to 
produce  a  stronger  strand.  Catgut  treated  in  this  way  lasts  in  the  tissues 
about  as  long  as  the  same  sized  strand  treated  by  most  of  the  other  methods 
in  vogue  at  the  present  time,  the  No.  2  gut  generally  requiring  about  one 
week  for  its  absorption.  I  have  not  found  that  the  material  so  treated  de- 
teriorates at  all  with  age,  neither  as  far  as  strength  or  sterility  is  concerned. 
In  fact,  I  have  recently  had  a  large  number  of  strands  bacteriologically  ex- 
amined from  a  jar  which  had  been  frequently  opened  during  the  past  year, 
and  have  yet  to  find  the  first  one  infected  or  in  any  other  way  undesirable 
for  use  in  surgery." 

All  material  that  can  be  boiled  for  one  hour  is  perfectly  safe  to  use  for 
sutures  which  are  to  be  removed  because  such  boiling  ensures  the  sterility 
of  the  material  at  the  time  it  is  placed  in  the  wound,  provided  it  is  not  in- 
fected during  its  introduction.  Of  course,  it  may  be  infected  while  passing 
through  the  skin  or  from  micro-organisms  which  progress  along  the  suture 
between  the  time  of  its  insertion  and  the  time  of  its  removal,  or  from  micro- 
organisms existing  in  the  blood  which  may  become  located  at  this  point  of 
traumatism,  but  if  the  stitches  are  not  tied  too  tightly  this  result  is  not  likely 
to  occur,  because  there  will  not  be  a  favorable  culture  medium  along  the 
stitch  unless  prepared  by  pressure  necrosis. 

TANNED  CATGUT. 
Ssobolew  Method. 

The  catgut  is  wound  loosely  upon  glass  slides.  It  is  immersed  for  24 
hours  in  extract  of  quebracho  to  which  one  per  cent,  of  phenol  has  been 
added;  It  is  then  washed  in  sterile  water  and  immersed  for  24  hours  in  an 
aqueous  solution  of  formalin  actually  4  per  cent,  but  10  per  cent,  of  commer- 
cial formalin  in  water.  It  is  then  washed  for  24  hours  in  running  water, 
then  boiled  for  15  minutes  in  water  and  while  still  hot  it  is  immersed  in  a 
mixture  of  96  per  cent,  strong  commercial  alcohol  91  parts,  glycerine  5 
parts  and  phenol  4  parts.  In  this  solution  it  may  be  preserved  indefinitely, 
being  washed  in  water  to  remove  the  phenol  before  using. 

It  may  also  be  placed  in  this  mixture  for  a  time  and  then  preserved 
indefinitely  in  the  iodoform,  ether,  alcohol  mixture  previously  described. 

The  finest  catgut  will  absorb  in  not  less  than  two  weeks,  and  the  larger 
sizes  in  from  two  to  six  weeks. 
Ligature  Material  Boiled  in  Paraffin. 

Of  the  boilable  materials  for  suturing  silk,  linen,  either  plain  or  cov- 
ered with  celluloid,  also  these  materials  boiled  in  paraffine  at  a  tempera- 
ture not  to  exceed  150  degrees  C.,  or  in  10  per  cent,  of  iodoform  in  par- 
affine, may  be  employed  with  perfect  safety  provided  the  sutures  extend 
through  the  surface  so  that  they  may  be  removed  or  that  only  the  very  fine 
threads  are  used  in  case  of  buried  sutures  or  ligatures. 

Hyper-tension  Favors  Suppuration. 

Many  surgeons  complain  of  suppuration  when  using  catgut  for  ligatures 
and  buried  sutures  who  are  much  more  fortunate  when  they  use  for  these 
purposes  only  the  finest  silk  or  linen.  \Ye  are  convinced  of  the  fact  that  this 
is  due  to  the  circumstances  that  when  using  catgut  an  amount  of  tension  is 
applied  in  tying  the  sutures  or  ligatures  which  would  break  the  fine  silk  or 
linen  and  consequently  when  using  the  latter  material  these  surgeons  cannot 


GENERAL    SURGICAL    CONSIDERATIONS  53 

cause  the  same  amount  of  pressure  necrosis  as  they  can  when  using  the 
much  heavier  catgut. 

DISINFECTION  OF  DRESSINGS. 

All  dressings  should  be  disinfected  in  a  steam  sterilizer,  two  hours  be- 
ing given  for  steaming  and  one  hour  for  drying.  The  same  treatment  is 
given  to  aprons,  sheets  and  towels. 

One-fourth  of  this  time  is  quite  sufficient  to  make  surgical  dressings 
absolutely  sterile,  as  has  been  demonstrated  by  hundreds  of  experiments, 
and  if  this  work  is  in  the  personal  care  of  one  who  has  been  entrusted  with 
it  for  a  long  period  the  time  may  be  reduced  accordingly,  but  if  it  is  as- 
signed to  the  nurses  in  general,  it  is  better  to  allow  more  time  than  is 
actually  required,  as  no  harm  is  done  to  the  dressing  material  by  exposing  it 
the  additional  time  to  the  superheated  steam  in  the  sterilizer. 

The  dressings  should  be  arranged  in  packages  and  placed  in  heavy  mus- 
lin bags  or  folded  in  thick  towels  securely  pinned  so  that  the  contents  will 
not  be  contaminated  when  these  packages  are  handled. 

Each  package  should  be  labeled  by  writing  the  name  of  the  contents 
on  the  covering  with  lead  pencil,  or  if  permanent  bags  are  used  always  for 
the  same  contents  these  may  be  permanently  labeled  with  indelible  ink  in 
order  that  it  may  never  be  necessary  to  examine  the  contents  to  find  what 
may  be  wanted. 

DISINFECTION  OF  EVERYTHING  COMING  DIRECTLY   IN  CONTACT 

WITH   WOUNDS. 

The  basins,  instrument  pans,  jars  for  dressings,  etc..  are  to  be  boiled 
in  soda  and  water  for  one  hour,  then  wrapped  up  in  sterilized  sheets  until 
used.  The  tables  should  be  scrubbed  with  soap  and  water  and  then  with 
i  :i,ooo  corrosive  sublimate  in  water,  and  have  them  always  covered  with  a 
double  sterilized  sheet  when  in  use.  The  ordinary  pads  of  cotton  and  of  gauze, 
sterilized  in  a  steam  sterilizer,  are  used  in  place  of  sponges  in  all  operations. 

A  one  per  cent,  solution  of  formaldehyde  in  water  is  very  satisfactory 
for  washing  all  of  these  apparati  and  especially  for  the  purpose  of  disinfect- 
ing bath  tubs  and  stationary  wash  basins.  The  latter  should,  however, 
never  be  used  in  operating  rooms  where  all  the  basins  for  washing  the 
hands  of  the  surgeon,  assistants  and  nurses  are  so  arranged  that  they  can  be 
removed  from  the  stands  and  boiled,  a  sufficient  number  of  these  removable 
basins  being  kept  ready  so  that  they  may  be  replaced  by  sterile  ones  between 
operations. 

The  nurses  who  scrub  these  various  utensils  with  these  strong  antiseptic 
solutions  should  invariably  wear  thick  rubber  gloves  while  performing  this 
portion  of  their  duties,  because  the  skin  of  their  hands  will  otherwise 
become  roughened  and  thus  constitute  a  danger  to  the  service  owing  to 
the  ease  with  which  infectious  material  may  become  lodged  in  the  crevices 
formed. 

DRAINAGE. 
When  Used. 

Drainage  is  always  used  in  very  large  wounds  such  as  breast  amputa- 
tions with  removal  of  the  pectoralis  major  and  minor  muscles  and  axillary 


54  GENERAL    SURGICAL    CONSIDERATIONS 

glands,  also  in  thigh  amputations,  usually  only  for  three  or  four  days; 
never  in  herniotomies  except  for  strangulated  hernia  complicated  with  gan- 
grene, nor  in  small,  clean  wounds. 

Rubber  Tubing. 

The  ordinary  perforated  rubber  tube  is  employed.  It  is  always  used  in 
wounds  that  are  primarily  septic;  and  whenever  there  is  any  doubt  as  to 
the  aseptic  condition  of  a  wound  we  drain.  We  have  found  the  use  of  an  ordi- 
nary leather  punch  very  convenient  for  making-  the  necessary  perforations 
in  rubber  tubing.  In  many  instances,  rubber  tubes  split  longitudinally 
throughout  seem  to  be  especially  useful. 

Glass  Tubes. 

In  wounds  in  which  the  pressure  from  the  dressing  would  be  likely  to 
cause  collapse  of  a  rubber  drainage  tube,  as,  for  instance,  in  operations  for 
the  removal  of  goitre,  the  small  perforated  glass  tubes  introduced  by 
Kocher  are  most  satisfactory.  They  may  be  kept  on  hand  in  various  forms 
both  straight  and  curved,  and  in  various  lengths  and  sizes,  in 'order  that 
they  may  suit  the  conditions  found  in  any  given  case. 

In  the  abdominal  cavity  we  use  glass  tubes,  closed  at  the  end,  having  a 
number  of  small  perforations  toward  the  lower  end.  A  strand  of  gauze  is 
carried  to  the  bottom  of  the  tube  to  act  as  a  capillary  drain.  A  piece  of 
iodoform  or  formidin  gauze,  folded  about  four  double,  is  placed  over  the 
glass  tube,  which  is  then,  with  this  covering,  carried  down  to  the  point 
to  be  drained.  In  operations  upon  the  pelvic  organs  it  is  carried  to  the 
bottom  of  the  cul-de-sac  of  Douglas. 

CIGARETTE  DRAIN. 

In  order  to  prevent  the  formation  of  adhesions  between  portions  of  the 
intestines  which  come  in  contact  with  the  gauze  covering  the  glass  drain  the 
latter  is  surrounded  on  the  side  directed  toward  intestines  or  stomach  by  a 
row  of  so-called  cigarette  drains,  introduced  by  Robert  Morris.  These 
drains  are  made  by  placing  one  or  more  layers  of  gauze  upon  a  piece  of 
gutta  percha  tissue  so  that  the  former  is  two  or  three  cm.  longer  and  five 
or  more  cm.  narrower  than  the  latter.  The  gauze  is  then  rolled  up  inside 
of  the  tissue  so  that  it  will  be  entirely  covered  by  the  latter  and  so  that  its 
ends  will  project  slightly  from  either  extremity,  giving  the  drain  the  appear- 
ance of  a  cigarette  varying  in  size  according  to  the  area  to  be  drained.  Thus 
a  capillary  drain  is  constructed  which  is  surrounded  by  a  non-irritating, 
soft,  pliable  covering  of  gutta  percha  tissue. 

A  similar  drain  can  be  made  by  splitting  a  soft  rubber  drainage  tube 
longitudinally  and  placing  a  strand  of  gauze  within  its  lumen. 

In  order  to  prevent  adhesions  and  also  to  facilitate  drainage,  flat  tapes 
of  sterile  gauze  saturated  with  vaseline  oil  may  be  used. 

The  gutta  percha  tissue  may  be  disinfected  by  washing  in  one  to  one 
thousand  of  corrosive  sublimate  in  water  and  by  exposing  the  moist  sheets  to 
the  fumes  of  formaldehyde.  The  material  will  not  bear  disinfection  by 
boiling  or  by  exposure  to  steam. 

IRRIGATION. 

\Ye  practically  never  use  irrigation  during  operations,  either  in  the 
abdominal  cavitv  or  elsewhere. 


GENERAL    SURGICAL     CONSIDERATIONS  55 

[During  the  early  days  of  my  surgical  work,  as  an  assistant,  I  observed 
that  wounds  in  abdominal  sections  healed  more  smoothly  than  in  other 
operations,  and  the  only  real  difference  in  the  treatment  observable  was 
the  fact  that  no  irrigation  was  used  in  connection  with  the  former,  while 
it  was  invariably  employed  in  the  others.  I  consequently  applied  the  same 
plan  of  treatment  to  all  wounds  as  early  as  1889,  and  have  since  constantly 
operated  dry  in  clean  cases,  and,  since  a  number  of  years,  also  in  cases  con- 
taining pus.  I  have  treated  wounds  in  circumscribed  tuberculous  lesions  by 
applying  strong  compound  tincture  of  iodine,  and  then  sponging  the  area 
with  moist  gauze  sponges  before  tamponing  with  iodoform  gauze  or  before 
closing  with  sutures.  These  wounds  have  progressed  well,  but  I  do  not 
feel  convinced  that  the  iodine  has  been  responsible  for  this  fact.  Very 
recently  in  tuberculosis  of  the  joints  I  have  applied  strong  carbolic  acid 
to  the  surfaces  of  the  bones  for  two  minvites,  and  have  then  washed  these 
parts  thoroughly  with  strong  alcohol  until  all  of  the  carbolic  acid  seemed 
removed.  I  am  convinced  that  irrigation  is  rarely  of  any  real  benefit  and 
that  it  is  frequently  harmful  in  carrying  infectious  material  to  portions 
which  might  otherwise  have  escaped  infection. — Ochsner.] 

Primary  Union  Depends  Upon  Thorough  System. 

Our  observations  have  convinced  us  that  it  is  an  exceedingly  simple  mat- 
ter to  obtain  primary  union  almost  invariably  if  one  has  a  reasonable  sys- 
tem, i.  e.,  a  system  which  keeps  the  attention  of  operator,  assistants  and 
nurses  constantly  on  guard  to  prevent  accidental  contamination. 

Whenever  some  new  method  is  on  trial  in  any  hospital  or  clinic  every 
one  is  interested  and,  consequently,  accidental  contamination  is  not  likely 
to  occur.  It  is  for  this  reason  that  the  various  new  methods  are  so  suc- 
cessful in  the  hands  of  their  originators. 

Theory  vs.  Practice  in  Surgical  Methods. 

A  close  observation  of  antiseptic  and  aseptic  surgery  from  its  begin- 
ning to  the  present  time  has  led  us  to  the  conclusion  that  there  is  a  vast 
amount  of  difference  and  contradiction  between  the  theories,  which  are  at 
present  generally  accepted,  and  the  practical  results.  So  far  as  a  scientific 
study  of  the  subject  is  concerned,  both  the  theoretical  considerations,  which 
are  mainly  based  upon  scientific  experiments,  and  the  practical  observations 
upon  wounds,  must  be  borne  in  mind.  So  far  as  the  welfare  of  any  par- 
ticular patient,  or  any  group  of  patients,  is  concerned,  only  those  facts 
which  practice  has  shown  to  be  of  importance  in  order  to  secure  primary 
union  should  be  considered,  because  they  will  bear  directly  upon  the  welfare 
of  a  human  being  who  has  entrusted  himself  to  our  care.  The  following 
conclusions  will  serve  to  express  my  position  upon  this  subject. 

1.  (a)     Theoretically  it  is  almost  impossible  to  absolutely  disinfect  the 
skin  of  the  patient  and  the  hands  of  the  operator. 

(b)  Practically  it  is  one  of  the  easiest  and  simplest  tasks  to  obtain  a 
degree  of  surgical  cleanness  that  will  insure  primary  wound-healing. 

2.  (a)     Theoretically,  strong  chemical  disinfectants  are  indicated  for 
the  purpose  of  disinfecting  the  hands. 

(b)  Practically,  careful  washing  with  the  mildest,  viz.,  soap  and 
water  and  alcohol,  is  absolutely  sufficient  and  very  much  safer  for  the  pa- 
tient, because  hands  roughened  by  the  use  of  strong  antiseptics  are  much 


56  GENERAL     SURGICAL     CONSIDERATIONS 

more  prone  to  become  hopelessly  septic  than  hands  which  are  covered  with 
smooth,  healthy  skin. 

3.  (a)     Theoretically,  it  is  extremely  simple  to  keep  the  hands  aseptic 
after  they  have  been  rendered  so. 

(b)  Practically,  there  is  no  more  difficult  task  in  any  clinic,  or  dur- 
ing an  operation  in  a  private  house,  than  to  keep  all  interested  hands  clean 
after  they  have  been  disinfected. 

4.  (a)      Theoretically,  sutures  passing  through  the  skin  and  the  deep 
tissues  underneath  are  a  menace  to  the  patient,  because  they  form  a  direct 
communication  between  the   skin,  containing   staphylococci,   and  the   deep 
tissues  which  are  primarily  sterile. 

(b)  Practically,  these  stitches  never  cause  an  infection,  unless  drawn 
too  tightly,  in  which  case  the  resulting-  pressure  necrosis  is  the  cause  of  the 
mischief  as  it  furnishes  these  micro-organisms  dead  tissue  to  thrive  upon. 

5.  (a)     Theoretically,  catgut  sutures  and  ligatures  are  objectionable, 
(b)      Practically,  if  applied  properly  by  a   clean   surgeon   with  clean 

assistants,  and  not  tied  too  tightly,  they  are  absolutely  satisfactory  and  not 
objectionable. 

6.  (a)     Theoretically,  it  is  as  safe  to  operate  upon  clean  cases  after 
dressing  suppurating  wounds  as  at  any  other  time. 

(b)  Practically,  surgeons  who  follow  this  practice  always  have  a 
great  amount  of  wound  infection,  on  account  of  accidental  contamination 
of  something  coming  in  contact  with  the  wounds. 

In  order  to  have  wounds  heal  without  suppuration  we  believe  the  fol- 
lowing conditions  should  be  enforced : 

1.  The  surgeon,  his  assistants  and  nurses,  must  be  habitually  clean, 
and  the  skin  of  their  hands  must  be  free  from  irritation  and  roughness. 

2.  Their  attention  should  constantly  be  directed  toward  the  prevention 
of  accidental  infection. 

3.  The   surgeon  and  his  assistants   should  be   careful  not  to  breathe 
or  speak  into  the  wounds. 

4.  Tissues  should  not  be  exposed  to  unnecessary  traumatism. 

5.  Sutures  should  not  be  tied   tightly  enough  to  cause  pressure  ne- 
crosis. 

6.  A   reasonable   system  should  be  employed  so  that  every  one  con- 
cerned can  assist  intelligently  in  preventing  infection. 

THE  OPERATING  ROOM. 
Direction  of  Light. 

The  hospitals  of  this  country  are  all  supplied  with  suitable  operating 
rooms,  with  the  one  criticism  that  many  of  them  are  badly-lighted.  The 
light  should  come  from  the  north  and  from  sky-lights  facing  north,  in  order 
to  have  uniform  brightness  and  not  direct  sun-light  and  to  avoid  the  over- 
whelming heat  which  is  caused  by  sky-lights  facing  the  sun. 

In  great  cities  operating  rooms  should  be  on  the  highest  floor  in  high 
buildings,  because  the  air  contains  much  less  street  dust  in  the  upper 
stories  of  a  high  building  than  near  the  ground,  and  consequently  less  in- 
fectious material  is  likely  to  accumulate  in  places  from  which  an  infection 
can  be  carried  to  the  wounds. 


GENERAL     SURGICAL     CONSIDERATIONS  57 

Advantages  of  the  Hospital. 

Operations  are  always  best  performed  \n  hospitals,  and  every  city  and 
town  in  the  country  should  support  a  hospital  suitable  in  size  to  the  com- 
munity tributary  to  it.  This  can  be  established  and  maintained  at  a  small 
cost  and  is  of  great  benefit  to  the  community  because  it  supplies  a  means 
of  proper  treatment  for  cases  which  must  otherwise  be  satisfied  with  gen- 
erally very  inefficient  care.  Moreover,  it  serves  as  the  most  powerful  in- 
centive for  the  entire  medical  profession  in  the  community  in  which  it  is 
maintained  because  it  furnishes  a  reasonable  opportunity  for  advancement. 

The  Leading  Consideration  in  the  Private  Home. 

But  many  operations  must  for  the  present  be  performed  in  the  homes 
of  patients  and  here  it  might  be  considered  more  difficult  to  arrange  an 
operating  room.  As  a  matter  of  fact  there  is  but  one  point  to  be  borne  in 
mind  in  the  arrangement  of  a  room  for  operating,  namely,  infection,  and 
that  no  wound  infection  is  to  be  considered  except  from  contact.  Not  that 
infection  from  the  air  is  absolutely  impossible  theoreticallly,  but  that,  prac- 
tically, a  wound  remains  aseptic  unless  infectious  material  has  been  placed 
in  it  by  dirty  hands,  dirty  instruments,  appliances  or  sponges,  ligatures,  su- 
tures or  dressings,  unless  the  infectious  material  existed  in  the  patient's 
body  at  the  time  of  operation.  Of  course  the  operator  could  infect  a  wound 
by  breathing  or  speaking  into  it  if  his  pharynx  or  air  passages  were  in- 
fected. 

Universal  Cleanliness  Required. 

But  in  any  case  in  which  a  clean  surgeon  with  clean  assistants  and 
clean  appliances  operates  upon  a  clean  patient,  it  can  be  expected  with  a 
fair  degree  of  certainty  that  the  wound  will  remain  aseptic,  no  matter  what 
the  surroundings  may  be.  On  the  other  hand,  the  most  perfectly  appointed 
operating  room  cannot  prevent  a  septic  surgeon  from  having  his  wounds 
in  clean  patients  suppurate. 

Details  of  Preparation  in  the  Private  Home. 

It  is  best,  when  compelled  to  operate  in  a  dwelling  house,  to  choose  the 
lightest  room,  to  make  as  little  disturbance  as  possible,  and  thus  avoid  stif- 
ring  up  dust,  to  arrange  everything  very  simply  and  to  utilize  the  least  pos- 
sible amount  of  furniture.  An  ordinary  extension  table  will  serve  admirably 
for  an  operating  table.  Let  it  be  drawn  out  so  that  there  is  a  space  of 
about  three  feet  in  the  center  and  then  two  of  the  boards  may  be  placed 
lengthwise  so  as  to  leave  a  notch  on  one  side  for  the  surgeon  to  stand  and 
on  the  other  side  for  his  assistant.  A  quilt  or  blanket  may  be  folded  upon 
itself  three  or  four  times  and  placed  lengthwise  upon  the  table  and  this 
covered  with  a  freshly  laundered  sheet.  A  small  stand  or  table  is  placed  at 
the  side  of  the  operator  and  covered  with  a  sterile  towel,  and  on  this  are 
placed  the  instruments,  ligatures,  sutures  and  sterilized  dressings.  Upon 
chairs  or  a  bench,  or  another  table,  two  or  three  basins  are  placed  containing 
boiled  water.  Into  one  of  these  a  sufficient  number  of  tablets  of  corrosive 
sublimate  are  thrown  to  make  a  solution  of  1-2,000. 

After  preparing  the  surface  to  be  operated,  and  the  surgeon's  hands 
as  described  in  a  previous  section,  the  operation  may  proceed,  but  every 
one  connected  with  the  work  must  bear  in  mind  throughout  the  operation 
that  nothing  is  to  be  touched  by  any  one  except  those  things  that  have 


been  sterilized.  If  anything  has  been  touched  by  accident  or  intentionally, 
the  hands  of  such  person  or  persons  must  again  be  disinfected. 

It  is  not  at  all  uncommon  after  making  the  most  careful  preparations 
for  an  aseptic  operation  to  have  some  one  who  comes  in  contact  with  the 
wound,  directly  or  indirectly,  thoughtlessly  produce  an  infection  by  handling 
some  object  which  is  not  sterile.  If  it  is  necessary  to  depend  upon  unskilled 
assistants,  it  is  well  to  cover  their  hands  with  sterilized  rubber  gloves  and 
to  virtually  perform  the  operation  alone.  It  is  well  to  carry  a  good  supply 
of  sterilized  towels  and  dressings  in  order  to  be  able  to  cover  everything  in 
the  vicinity  of  the  operation. 

Instruments  may  be  carried  sterile  in  a  canvas  roll  and  covered  with  a 
sterile  towel,  and  the  ligatures  and  suture  material  may  be  carried  in  bot- 
tles. Basins  may  be  placed  in  a  wash  boiler  and  sterilized  by  boiling  while 
the  preparations  are  being  made  for  the  operation. 

Sterilized  gauze  may  be  cut  in  suitable  lengths  to  serve  as  sponges. 

From  this  it  will  be  seen  that  it  is  not  very  difficult  to  prepare  an  op- 
erating room  in  an  ordinary  dwelling  house,  but  no  operator  ever  does  his 
best  work  anywhere  except  in  his  regular  operating  room. 

Simplicity  of  Detail  to  be  Studied. 

Whether  the  operation  be  performed  in  a  well-appointed  operating 
room  or  in  a  dwelling  house,  much  will  be  gained  for  the  patient  if  the 
surgeon  appreciates  the  great  value  of  simplicity.  If  only  that  is  done  which 
is  actually  of  value  to  the  patient,  much  will  be  gained  for  him,  because  it  is 
through  unnecessary  manipulations  that  one  is  especially  likely  to  carry  in- 
fection to  the  wound. 

GENERAL  ANESTHESIA. 

Ether  and  chloroform  are  the  only  two  general  anesthetics  which  seem 
to  have  stood  the  test  of  time ;  not  that  they  are  entirely  safe,  nor  that  they 
are  entirely  satisfactory,  but  rather  that  they  are  less  unsatisfactory  than 
the  other  substances  which  have  come  into  use  and  been  discarded  again. 
With  chloroform  there  is  a  considerable  amount  of  danger  at  the  time  of 
its  administration,  and  in  the  use  of  ether  there  is  some  danger  from  pneu- 
monia following  recovery  from  the  anesthesia  because  of  the  great  irritation 
of  the  respiratory  tract. 

The  various  contra-indications  will  be  considered  in  connection  with 
the  clinical  cases  wherein  they  are  found.  For  the  present  only  points  of 
general  application  will  be  considered. 

General  Influences. 

The  careful  general  examination  which  was  described  in  the  first  sec- 
tions will  have  determined  any  pathological  conditions  of  the  heart,  the  kid- 
neys and  the  lungs,  the  three  organs  especially  to  be  studied  by  the  anes- 
thetist. If  one  or  more  of  these  organs  have  been  found  to  be  pathological  it 
will  be  wise  for  the  anesthetist  to  be  even  more  cautions  than  he  would 
otherwise,  if  this  is  possible,  and  for  the  surgeon  to  limit  his  operation  to  the 
very  shortest  consistent  time.  The  induction  of  anesthesia  should  be  some- 
what slower  and  the  anesthesia  just  sufficiently  profound  to  premit  the  op- 
eration without  disturbance  or  interruption  by  the  patient. 
Organic  Heart  Lesions  Not  Positively  Forbidding. 

Singularly,    in   our   experience   patients   suffering   from    organic   heart 


GENERAL    SURGICAL     CONSIDERATIONS  59 

lesions  have  never  had  any  serious  or  alarming  difficulty  during  the  admin- 
istration of  an  anesthetic,  while  patients  whose  heart,  lungs  and  kidneys 
were  normal  at  the  time  of  administering  anesthetics  have  sometimes 
shown  serious  symptoms. 

In  a  symposium  on  this  subject  before  the  College  of  Physicians  of 
Philadelphia  in  which  many  of  the  most  experienced  surgeons  of  this 
country  participated,  no  one  had  seen  a  death  from  anesthesia  in  any  case 
in  which  there  had  been  a  demonstrable  heart  lesion. 

No  one  would  reason  from  this  that  the  former  class  of  patients  are 
better  subjects  for  the  administration  of  anesthetics,  but  rather  that  the 
presence  of  their  unfavorable  condition  caused  the  anesthetists  to  exercise 
unusual  care  in  all  of  them. 

From  this  it  would  seem  that  it  is  perfectly  safe  to  give  anesthetics  in 
cases  suffering  from  valvular  heart  lesions,  provided  this  is  known  at  the 
time  the  anesthetic  is  administered.  We  believe  that  it  also  shows  that  if  the 
same  care  which  has  been  employed  in  these  cases  were  regularly  taken  in 
all  cases,  the  present  low  mortality  from  anesthesia  would  be  still  further 
reduced. 

Chloroform  Followed  by  Ether. 

The  method  of  administering  chloroform  followed  by  ether  which  has 
been  most  satisfactory  in  our  own  practice,  consists  in  first  quieting  the 
fears  of  the  patient,  then  applying  across  the  patient's  eyes  a  piece  of  rub- 
ber ten  cm.  wide  and  fifteen  cm.  long  and  over  this  a  pad  of  sterilized  gauze, 
six  or  eight  thicknesses,  and  about  three  inches  wide  and  eight  inches  long, 
held  in  place  by  a  towel  which  is  pinned  around  the  head  so  that  its  lower 
margin  crosses  the  nose  below  its  middle  to  protect  the  eyes  against  irrita- 
tion from  the  anesthetic,  and  incidentally  to  soothe  the  patient  by  having  the 
eyes  closed.  The  face  is  then  anointed  with  vaseline  to  prevent  burning 
with  chloroform.  An  ordinary  Esmarch  chloroform  mask  covered  with  two 
thicknesses  of  gauze  is  then  placed  over  the  mouth  and  nose  and  chloroform 
is  dropped  upon  this  very  slowly  but  continuously,  care  being  taken  to  con- 
stantly change  the  point  upon  which  the  drops  fall  so  as  to  apply  the  chloro- 
form to  different  parts  of  the  imsk  with  some  uniformity.  Then  the 
patient  is  told  to  count  aloud  slowly  after  the  anesthetist,  who 
speaks  numbers  of  three  figures  slowly,  then  waits  for  the  pa- 
tient to  repeat  the  same  number,  then  he  calls  the  next  higher  or  lower 
number.  This  is  continued  until  the  patient  is  asleep.  By  choosing  a  large 
number  to  be  repeated  by  the  patient  the  latter  exhales  freely  while  counting 
and  later  inhales  quite  as  freely  while  the  anesthetist  repeats  the  next  num- 
ber. His  attention  being  directed  toward  the  unusual  feature  prevents  him 
from  causing  any  voluntary  irregularity  in  his  respiration.  This  causes  him 
to  breathe  deeply  and  at  the  same  time  to  divert  his  attention  from  the 
anesthesia. 

So  long  as  the  patient  counts  with  loud  voice,  after  the  anesthetist, 
his  breathing  is  fairly  regular  and  there  is  little  danger  in  the  administra- 
tion of  chloroform,  provided  the  gauze  covering  the  mask  is  not  too  thick  to 
permit  a  sufficient  amount  of  air  to  enter  with  the  chloroform  (for  this  rea- 
son only  two  thicknesses  of  ordinary  gauze  should  be  used). 

After  the  patient  has  been  thoroughly  anesthetized  with  chloroform, 
and  for  at  least  one  minute  before  the  operation  is  begun,  ether  is  admin- 
istered with  the  same  mask,  also  by  the  drop  method,  with  the  difference, 


60  GENERAL     SURGICAL     CONSIDERATIONS 

however,  that  the  gauze  is  kept  thoroughly  saturated  with  ether  and  that 
four  layers  of  gauze  are  placed  on  the  Esmarch  mask  instead  of  two. 

Safety  of  the  Method. 

When  a  surgeon  is  compelled  to  operate  without  a  skilled  anesthetist, 
which  is  a  very  common  experience  for  the  practitioner  in  the  country,  the 
administration  of  the  ether  can  safely  be  placed  in  the  hands  of  any  one, 
provided  this  method  be  employed.  The  surgeon  can  prepare  everything 
for  the  operation,  he  can  then  give  the  chloroform  himself  until  the  patient 
is  asleep,  then  after  giving  ether  for  a  minute  or  more  this  can  be  placed 
in  the  hands  of  any  intelligent  person  and  the  surgeon  can  again  disinfect 
his  hands  and  proceed  to  perform  the  operation.  Even  in  hospitals  where 
there  are  skilled  anesthetists  this  method  is  satisfactory. 

If  for  any  reason  the  patient  does  not  take  ether  well  he  will  frequently 
take  chloroform  without  disturbance,  and  it  is  usually  well  to  change  the 
anesthetic  in  any  case  in  which  there  seems  to  be  difficulty  with  giving  one 
or  the  other  of  these  two.  We  have,  however,  adopted  the  rule  never  to  re- 
turn to  the  use  of  chloroform  in  any  given  case  in  which  this  anesthetic  is 
not  well  taken,  fearing  that  it  might  result  in  a  serious  or  even  fatal  accident. 

If  a  patient  does  not  take  ether  well  it  may  be  disagreeable  to  continue 
its  use,  but  it  is  nevertheless  ordinarily  safe. 

Danger  Signals. 

There  is  no  sign  of  danger  in  the  administration  of  anesthetics  upon 
which  one  can  depend  absolutely,  but  there  are  a  number  of  signs  which 
should  always  have  immediate  and  careful  attention  when  they  appear.  In 
most  cases  of  danger  respiration  is  at  first  impaired ;  in  some  the  respiration 
and  the  circulation  suffer  at  the  same  time,  while  in  others  the  heart 
stops  beating  suddenly  before  the  respiration  ceases. 

Means  of  Relief. 

In  time  of  trouble  we  have  found  greater  benefits  and  prompter  relief  by 
first  pressing  forcibly  upon  the  chest  several  times,  in  order  to  force  out 
from  the  lungs,  as  much  as  possible,  the  air  laden  with  chloroform,  and 
then  by  means  of  artificial  respiration  supplying  pure  air  in  its  place. 

If  no  air  seems  to  enter  the  lungs  upon  attempting  artificial  respiration 
it  is  well  to  rapidly  place  a  gag  between  the  teeth  and  with  the  finger  to 
raise  up  the  epiglottis  away  from  the  larynx ;  this  can  sometimes  be  accom- 
plished very  quickly  by  pulling  the  tongue  forward  rapidly  with  a  pair  of 
tongue  forceps. 

The  operator  can  frequently  recognize  impending  danger  to  the  patient 
from  the  anesthetic  by  the  lack  of  bleeding  from  the  wound  and  by  the 
dark  color  of  the  blood,  indicating  insufficient  aeration. 

Above  all  things,  the  anesthetist  should  give  his  entire  attention  to  his 
work  and  should  never  crowd  the  anesthetic  in  order  to  hasten  the  anes- 
thesia. 

Preference  Given  to  Ether. 

For  several  years  we  have  abandoned  the  use  of  chloroform  anesthesia 
completely  because  it  has  been  found  that  by  using  the  drop  method  of  ad- 
ministering ether,  which  was  first  introduced  in  the  Augustana  Hospital  by 
L.  H.  Prince  twenty  years  ago,  anesthesia  can  be  accomplished  almost  with- 
out either  immediate  or  remote  danger.  The  amount  of  ether  given  is  thus 
exceedingly  small,  and  the  patient  is  completely  under  its  influence,  in  from 


GENERAL    SURGICAL    CONSIDERATIONS  6l 

two  to  ten  minutes.  In  cases  in  which  two  ounces  of  castor  oil  has  been 
given  on  the  day  before  the  operation,  nausea  and  vomiting  rarely  occurs. 
The  patient  recovers  from  the  anesthetic  very  rapidly  and  without  pul- 
monary irritation. 

The  mask  invented  by  Ferguson,  which  is  constructed  of  malleable 
copper  wire  so  that  it  can  be  accurately  fitted  to  the  patient's  face,  is  most 
useful ;  the  amount  of  ether  given  can  be  most  accurately  regulated  and 
much  waste  is  therefore  prevented. 

Morphin  and  Atropin  Hypodermically. 

In  patients  with  irritable  bronchial  mucous  membranes  it  is  well  to  ad- 
minister one-fourth  grain  of  morphine  and  one  one-hundredth  grain  of  atro- 
pine  hypodermically  half  an  hour  before  beginning  the  anesthetic.  This 
will  prevent  the  accumulation  of  frothy  mucus  during  the  administration 
of  the  anesthetic,  which  is  especially  desirable  in  operations  about  the  neck 
This  also  reduces  the  amount  of  ether  required  for  accomplishing  satisfac- 
tory anesthesia. 

It  is  to  be  remembered,  however,  that  whatever  anesthetic  and  what- 
ever method  of  administration  may  be  chosen  it  is  always  of  great  im- 
portance to  the  patient  to  reduce  the  time  limit  to  a  minimum. 

NITROUS  OXIDE  GAS  ANESTHESIA. 

During  the  past  twelve  years  many  surgeons  have  used  nitrous  oxide 
gas  anesthesia  for  operations  lasting  up  to  and  even  beyond  one  hour.  This 
gas  has  been  used  safely  in  an  enormous  number  of  dental  operations,  and 
in  other  short  term  operations  for  many  years  with  great  satisfaction. 

No  Advantage  As  An  Introductory  Agent. 

Of  late  it  has  been  used  for  general  operative  work  in  many  cases  for 
the  purpose  of  anesthetizing  the  patient  primarily  to  avoid  the  annoyance  of 
taking  ether  and  later  continuing  the  anesthesia  with  ether  or  chloroform. 
In  order  to  determine  the  value  of  this  method  we  employed  it  in  one  hun- 
dred successive  cases  and  compared  the  anesthesia,  the  patient's  sensations 
and  the  condition  of  the  patient  after  the  operation  with  cases  operated 
before  and  after  this  test  period  under  ether  anesthesia  applied  by  the  drop 
method.  We  found  no  difference  in  the  course  of  the  anesthesia,  nor  in  the 
comfort  of  the  patient,  but  there  was  a  little  more  bronchial  irritation  fol- 
lowing operation  when  nitrous  oxide  gas  had  been  used.  The  method  was 
more  cumbersome  and  consequently  it  was  permanently  abandoned.  For  a 
time  it  was  necessary  to  give  patients  the  choice  of  this  anesthetic  because 
they  had  obtained  the  idea  elsewhere  that  it  was  much  safer  and  so  some 
were  slightly  prejudiced  in  favor  of  the  method,  but  aside  from  this  slight 
advertising  value,  wHich  the  method  undoubtedly  possesses,  we  are  convinced 
that  it  has  no  especial  value  as  compared  with  ether  properly  administered 
by  the  drop  plan. 

The  same  value  is  present,  possibly  to  a  somewhat  greater  degree,  in 
the  method  now. more  frequently  employed  of  a  combination  of  nitrous  oxide 
gas  and  oxygen.  Here  the  patient  is  successively  asphyxiated  by  the  use 
of  nitrous  oxide  gas  and  resuscitated  by  the  oxygen  gas.  A  skilled  anes- 
thetist can  accomplish  these  two  processes  so  cleverly  that  any  operation  not 
affected  by  muscular  rigidity  can  be  performed  under  this  anesthesia. 


62  GENERAL    SURGICAL     CONSIDERATIONS 

This  Form  of  Anesthesia  Not  Good  in  Intra-Abdominal  Work. 

In  intra-abdominal  operations  we  have  found  that  additional  traumatism 
necessitated  by  the  rigidity  of  the  abdominal  muscles  causes  a  great  increase 
in  the  pain  suffered  by  the  patient  after  operation.  This  can,  however,  be 
overcome  by  giving  from  one-sixth  to  one-third  of  a  grain  of  morphia  with 
one  one-hundredth  of  a  grain  of  atropine  half  an  hour  before  the  operation 
is  commenced,  and  by  giving  morphia  after  operation  in  case  of  pain.  The 
method  undoubtedly  exposes  the  patient  to  conditions  which  cannot  be 
considered  harmless.  Were  a  patient  exposed  to  the  same  degree  of  asphy- 
xia, for  the  same  period  of  time,  from  any  other  cause,  it  seems  reasonable  to 
suppose  that  any  physician  would  look  upon  this  as  a  severe  strain  upon 
the  physiological  processes.  After  the  newness  of  this  method  has  worn 
off,  these  secondary  considerations  will  undoubtedly  receive  more  careful 
attention. 

Other  Contraindications. 

It  seems  wise  never  to  follow  this  course  of  anesthesia  in  any  opera- 
tion lasting  longer  than  a  few  minutes,  unless  a  well  trained  anesthetist  is 
available,  and  then  never  in  plethoric  patients  nor  in  cases  suffering  from 
cardiac  dilatation,  myocarditis,  valvular  heart  lesions,  nor  in  those  suffering 
from  obstruction  to  respiration  from  any  cause.  Patients  with  arterio- 
sclerosis or  with  high  blood  pressure  are  also  bad  subjects  for  the  use  of 
this  form  of  anesthesia. 

In  cases  in  which  this  form  of  anesthesia  seems  safe,  it  is  not  needed 
because  they  do  equally  well  with  the  use  of  ether  by  the  drop  method,  and 
in  cases  in  which  one  dislikes  to  give  ether  this  method  is  contra-indicated. 
For  some  time  to  come  there  will  be  a  certain  amount  of  advertising  advan- 
tage, but  as  soon  as  this  has  been  dissipated  by  the  fact  that  everyone  will 
be  prepared  to  administer  this  form  of  anesthesia,  its  drawbacks  must  be- 
come apparent  as  compared  with  its  advantages. 

Properly  Conducted  Ether  Anesthesia  Has  All  Advantages. 

The  only  real  merits  are  the  comfort  to  the  patient  in  inducing  the 
anesthesia,  and  the  rapidity  with  which  patients  regain  consciousness.  The 
ether  anesthesia  when  applied  properly  by  the  drop  method  is  no  less  com- 
fortable, and  if  interrupted  when  the  surgeon  begins  to  apply  the  sutures 
the  patient  will  awaken  almost  immediately  after  the  conclusion  of  the  op- 
eration, but  will  then  usually  again  fall  asleep  and  so  remain  naturally  for 
several  hours,  while  after  nitrous  oxide  anesthesia  he  is  likely  to  be  kept 
awake  by  the  pain  in  the  wound  unless  morphia  is  administered.  Bronchial 
irritation  is  not  more  common  after  ether  anesthesia,  if  carried  out  as  de- 
scribed heretofore,  than  after  nitrous  oxide  anesthesia.  If  the  plan  of  ad- 
ministering two  ounces  of  castor  oil  twenty-four  hours  before  the  operation 
is  strictly  adhered  to,  there  is  almost  no  vomiting,  no  matter  what  anesthetic 
may  be  employed. 

LOCAL    ANESTHESIA    OR    ANALGESIA. 

The  use  of  nitrous  oxide  anesthesia  is  especially  contra-indicated  in 
conditions  such  as  severe  anemia,  lowered  or  much  increased  blood  pressure, 
diabetes,  advanced  nephritis,  status  lymphaticus,  morbus  Basedowi,  Addi- 
son's  disease,  myocarditis,  advanced  cardiac  and  pulmonary  disease.  In 
these  cases  the  use  of  local  anesthesia  should  be  considered. 

There  should  be  no  doubt  as  to  the  extent  of  the  operation,  because  the 


GENERAL    SURGICAL    CONSIDERATIONS  63 

anesthetic  being  limited  to  a  local  area,  dragging  of  the  tissue  may  affect 
other  organs  beyond  the  area  of  anesthesia.  In  some  instances  the  admin- 
istration of  a  local  anesthetic  may  be  more  painful  than  the  operation  itself, 
and  this  would,  of  course,  bar  its  use.  All  anesthetics  have  their  disadvan- 
tages and  dangers. 

Consciousness  a  Disadvantage. 

Consciousness  during  the  operation  is  a  great  disadvantage  to  the  op- 
erator unless  he  has  the  confidence  of  the  patient.  It  is  almost  impracticable 
with  many  nervous  individuals  and  children.  In  such  the  shock  of  appre- 
hension may  be  greater  than  that  which  may  result  from  the  use  of  a  general 
anesthetic. 

Methods  of  Action. 

Local  anesthetics  act  in  one  of  three  ways,  viz. :  ist,  By  producing  an 
anemia  of  the  capillaries  supplying  the  nerve-endings.  2d,  By  direct  action 
on  the  nerve-endings.  3d,  By  direct  action  on  the  nerve-fibres. 

When  about  to  perform  an  operation  under  local  anesthesia  all  prepara- 
tions should  be  completed  before  the  patient  is  brought  into  the  room.  Dur- 
ing the  operation  the  patient's  face  should  be  covered,  unnecessary  con- 
versation should  be  avoided  and  comparative  silence  should  prevail.  Stimu- 
lants should  be  at  hand,  and  the  patient  should  be  carefully  watched. 

The  chief  object  of  this  method  is  to  produce  anesthesia  over  a  limited 
area,  therefore  a  constricting  band  above  the  field  of  operation  or  the  use  of 
adrenalin  are  advisable,  for,  not  only  do  they  limit  the  field  of  action  but 
they  also  diminish  the  amount  of  anesthetic  required  and  the  hemorrhage 
following. 

Most  Common  Drugs. 

The  drugs  most  commonly  used  for  the  purpose  of  producing  local 
anesthesia  are  cocaine,  beta-eucaine,  novocain,  tropococain  and  ethyl-chlo- 
ride. We  have  been  in  the  habit  of  using  cocaine  for  a  number  of  years  and 
to  entire  satisfaction. 

Cocaine. 

Cocaine  when  applied  to  the  unbroken  skin  produces  no  effect.  When 
applied  to  the  mucous  membrane  or  when  injected  beneath  the  skin  it 
causes  a  tingling  sensation,  followed  by  a  paralysis  of  sensation  due  to  its 
toxic  effect  upon  the  nerve-endings.  It  also  produces  anemia  from  con- 
striction of  the  capillaries,  followed  by  hyperemia  from  secondary  dilata- 
tion. The  local  action  of  cocaine  is  very  brief,  after  which  it  is  rapidly  ab- 
sorbed, and  may  produce  constitutional  symptoms. 

At  first  the  use  of  cocaine  was  limited  to  small  areas,  later  the  applica- 
tion of  the  constriction  band  above  the  field  allowed  more  surface  to  be 
used  so  that  more  extensive  operations  could  be  performed.  With  the  dis- 
covery of  adrenalin,  Braun  suggested  its  use  in  combination  with  cocaine. 
The  danger  of  the  former  method  was  that  it  only  delayed  constitutional 
symptoms.  Adrenalin  being  a  hemostatic  diminishes  hemorrhage,  retards 
absorption  and  limits  the  action  of  the  cocaine  to  a  given  area,  consequently 
a  less  amount  is  necessary  and  the  anesthesia  is  prolonged  from  one  to 
three  hours. 

Preparation  of  Solution. 

Cocaine  hydrochloride  is  the  preparation  most  frequently  used.     It  is 


64  GENERAL  SURGICAL  CONSIDERATIONS 

soluble  in  chloroform,  alcohol  and  water.  In  the  preparation  of  the  aqueous 
solution  for  surgical  purposes,  great  care  must  be  taken  in  the  process  of 
sterilization  and  in  the  avoidance  of  chemical  contamination.  Only  a  physio- 
logical salt  solution  in  distilled  water  should  be  used.  This  is  very  im- 
portant, otherwise  intense  burning  sensation  may  follow  its  application.  As 
cocaine  loses  its  anesthetic  property  when  brought  to  the  boiling  tempera- 
ture (100  C.)  sterilization  may  be  accomplished  by  heating  the  solution  at 
80  C.  for  one-half  hour  on  two  successive  days.  After  the  solution  is 
sterilized  and  the  temperature  reduced  to  blood-heat,  an  equal  amount  of 
a  one  to  one  thousand  solution  of  adrenalin  chloride  is  added.  Adrenalin 
decomposes  at  boiling  temperature.  An  air-tight  metal  or  glass 
syringe  is  very  essential.  The  needle  is  inserted  just  beneath 
and  almost  parallel  with  the  epidermis  in  the  direction  of  the  line  of  incision. 
The  solution  is  then  slowly  injected  until  an  anemic  area  is  produced  into 
which  the  needle  is  gradually  advanced,  more  solution  being  injected  con- 
tinuously. When  the  needle  will  not  advance  any  further,  it  is  withdrawn 
and  the  process  then  repeated.  By  injecting  just  beneath  the  epidermis  the 
cocaine  comes  in  direct  contact  with  the  nerve-endings  and  there  is  very 
little  absorption. 

Schleich's  Infiltration  Method. 

In  cases  such  as  goitre  and  extensive  lipomata  in  which  a  large  amount 
of  solution  is  required,  this  method  is  preferred. 

Schleich  employs  three  solutions  containing  0.2  (strong),  o.i  (normal), 
o.oi  (weak)  parts  of  cocaine  hydrochloride,  to  which  are  added  sodium 
chloride  0.2,  morphine  hydrochloride  0.025,  and  sterile  distilled  water  suf- 
ficient to  make  100  parts. 

For  this  method  a  long  needle  is  required.  The  solution  is  injected 
just  beneath  the  epidermis  and  then  into  the  deeper  tissues  about  the  diseased 
area.  By  this  means  anesthesia  is  partly  produced  by  the  cocaine  and  part- 
ly by  the  pressure  of  the  water. 

As  much  as  100  cc.  of  the  weak  solution  may  be  used  before  the  in- 
cision is  made  and  later  during  the  progress  of  the  operation  it  is  perfectly 
safe  to  inject  up  to  500  cc. 

REGIONAL  ANESTHESIA. 

This  method  of  anesthesia  was  first  introduced  by  Braun  and  is  of  great 
practical  value  in  certain  operations  which  may  be  too  extensive  for  the  in- 
filtration method  and  in  which  a  general  anesthetic  is  contra-indicated.  This 
is  especially  true  for  operations  on  the  extremities,  but  in  order  that  it  may 
be  carried  out  successfully  an  accurate  knowledge  of  the  peripheral  nerves 
is  essential. 

Where  the  peripheral  sensory  nerves  are  superficial,  as  in  the  hands 
and  feet,  the  transverse  circular  or  semi-circular  subcutaneous  infiltration 
of  a  2  per  cent,  cocaine  solution  will  render  the  skin  below  insensible  to  pain. 
This  method  is  frequently  employed  for  operations  on  the  fingers  and  toes. 

Perineural  Method. 

For  the  performance  of  operations  on  the  extremities  in  which  deep 
anesthesia  is  required,  the  injection  of  a  2  per  cent,  solution  of  cocaine  an'4, 
adrenalin  about  the  nerve  sheath  will  paralyze  the  nerve  in  from  ten  to 
thirty  minutes,  and  anesthesia  of  the  parts  to  which  it  is  distributed  will 


GENERAL    SURGICAL     CONSIDERATIONS  65 

last  from  one  to  three  hours.  This  is  known  as  the  perineural  method  of 
anesthesia.  No  harm  is  done  to  the  nerve  and  the  shock  which  so  fre- 
quently follows  the  section  of  a  large  nerve  trunk  is  avoided. 

Accessible  Nerves. 

The  following  nerves  are  accessible  for  this  method : 

The  supra-orbital  branch  of  the  trigeminal  just  above  the  supra- 
orbital  notch. 

The  ulnar  behind  the  internal  condyle  of  the  humerus  beneath  the  deep 
fascia  where  it  perforates  the  internal  intermuscular  septum,  also  above 
the  wrist  beneath  the  inner  side  of  the  flexor  carpi  ulnaris. 

The  median  just  above  the  annular  ligament  of  the  wrist  on  the  inner 
side  of  the  palmaris  longus. 

The  internal  popliteal  along  the  inner  border  of  the  biceps  tendon  be- 
hind the  head  of  the  fibula. 

The  occipital  major  as  it  passes  through  the  outer  border  of  the  trape- 
zius. 

The  auricuo-temporal  as  it  passes  backward  and  outward  between  the 
lateral  ligaments  of  the  temporo-maxillary  joint  and  the  condyle  of  the  jaw 
close  to  the  temporal  artery. 

The  lingual  at  the  point  where  the  palato-glossal  fold  and  the  floor  of 
the  mouth  meet. 

The  great  auricular,  occipital  minor  and  the  superficial  cervical  along 
the  posterior  border  of  the  sterno-cleido-mastoid. 

The  superior  laryngeal  behind  the  cornua  of  the  hyoid  bone  where  it 
passes  through  the  thyro-hyoid  membrane. 

The  dorsal  nerve  of  the  penis  in  the  region  of  the  dorsal  artery. 

Endoneural  Method. 

It  has  been  found  that  by  injecting  a  i  per  cent,  cocaine  solution  with 
adrenalin  directly  into  the  nerve  trunk  the  same  results  may  be  obtained 
as  with  the  perineural  method.  This  is  known  as  the  endoneural  method. 
The  only  advantage  is  that  anesthesia  is  produced  more  promptly.  The  dis- 
advantages are  that  it  can  only  be  used  on  large  nerve  trunks.  The  nerve 
must  first  be  exposed  and  not  infrequently  does  a  neuritis  follow.  This 
method  may  be  used  on  the  crural,  the  sciatic  and  the  brachial  plexus. 

Bodine  and  Gushing  have  introduced  a  method  of  anesthesia  for  hernia 
operations.  They  start  the  operation  with  the  infiltration  method  and  then 
inject  the  ilio-hypogastric  and  ilio-inguinal  nerves  as  the  operation 
progresses. 

Intravenous  Method. 

The  latest  method  of  regional  anesthesia  is  that  which  was  introduced 
by  Bier  and  is  known  as  vein  anesthesia.  While  as  yet  it  is  not  generally  ac- 
cepted by  the  profession  it  is  of  some  practical  value  and  therefore  worthy 
of  mention. 

It  is  only  used  for  operations  on  the  extremities. 

The  blood  is  first  carefully  expelled  from  the  extremity  by  bandaging 
from  the  periphery  toward  the  field  of  operation.  A  soft  rubber  bandage  is 
then  applied  above  the  field  so  as  to  produce  constriction  over  a  broad  sur- 
face. A  second  similar  bandage  is  then  applied  below.  A  subcutaneous 
vein  between  the  two  bandages  is  then  exposed  and  a  weak  solution  of  co- 
caine i,s  injected  toward  the  valves.  Anesthesia  usually  follows  in  two  to 


66  GENERAL    SURGICAL     CONSIDERATIONS 

fifteen  minutes.  The  cocaine  is  dissolved  in  a  physiological  salt  solution 
which  penetrates  the  walls  of  the  veins  and  acts  on  the  nerve  endings  as  well 
as  the  nerve  trunks.  The  bloodless  condition  of  the  parts  allows  of  very 
little  absorption  and  a  large  part  of  the  solution  escapes  from  the  wound. 
so  that  there  is  very  little  danger  of  constitutional  symptoms.  To  further 
insure  safety,  Bier,  before  closing  the  wound,  removes  the  peripheral  band- 
age and  loosens  the  proximal  so  that  the  arteries  are  open  but  the  veins  are 
still  compressed.  When  the  limb  is  pink  and  bleeds  freely  the  tissues  are 
thoroughly  washed  in  order  to  remove  as  much  as  possible  of  the  solution. 
The  bandage  is  again  tightened  and  the  wound  sewed  up  before  anesthesia 
subsides.  If  a  large  amount  of  anesthetic  has  been  used,  Bier  washes  the 
vessels  through  a  canula  with  physiological  salt  solution,  which  runs  out 
through  the  wound.  Bier  refrains  from  using  this  form  of  anesthesia  in 
senile  or  diabetic  cases. 

It  may  be  used  for  operations  on  the  extremities  as  a  substitute  for 
spinal  anesthesia,  being  more  simple  and  harmless. 

SPINAL   ANESTHESIA. 

Spinal  anesthesia  was  first  introduced  by  Bier  following  the  discovery 
by  Corning,  that  cocaine  when  applied  to  a  nerve  trunk  produces  anesthesia 
of  the  region  which  it  supplied. 

Dangers  and  Disadvantages. 

The  mortality  following  tlr's  form  of  anesthesia  is  far  greater  than  after 
ether,  and  therefore  should  only  be  used  when  the  patient  can  not  take  the 
latter  and  when  local  or  regional  anesthesia  is  impracticable.  It  has  no  ad- 
vantage over  ether.  The  headache,  nausea  and  retching  which  may  follow 
its  use  may  be  more  persistent  than  after  ether,  so  that  a  spinal  puncture 
may  be  required  to  relieve  it.  Collapse  and  even  sudden  death  may  occur 
during  its  application.  Focal  paralysis  and  even  trophic  disturbances  may 
follow  its  use.  With  the  introduction  of  newer  methods  of  cocainization, 
its  use  is  now  practically  limited  to  the  upper  half  of  the  abdomen. 

There  is  no  pulmonary  irritation.  The  patient  being  conscious  may 
be  able  to  aid  the  operator.  There  is  complete  muscular  relaxation  and 
no  intestinal  protrusion. 

But  it  may  fail  in  its  purpose.  Any  accident  during  the  operation 
alarms  the  patient  and  embarrasses  the  surgeon.  In  advanced  cases  of 
cardiac  disease,  the  shock  of  apprehension  may  be  worse  than  that  from 
the  operation  itself.  The  operation  must  be  completed  within  an  hour  and 
a  half.  Pelvic  cases  are  unsafe  unless  the  Trendelenburg  posture  is  dis- 
pensed with.  Spinal  anesthesia  cannot  be  stopped  once  it  is  started. 

Injury  to  the  spinal  cord  ;  hemorrhage  into  the  subdural  space  ;  infec- 
tion of  the  meninges,  and  anesthesia  of  the  higher  centers  are  the  chief  dan- 
gers. 

The  main  object  in  the  production  of  spinal  anesthesia  is  to  localize  the 
action  of  the  drug.  In  order  to  do  this  diffusion  and  gravitation  must  be 
overcome.  The  specific  gravity  of  the  spinal  fluid  is  1.007,  therefore,  a  so- 
lution of  greater  or  lesser  specific  gravity  is  safer,  this  depending  on  the 
position  of  the  patient.  The  use  of  spinal  fluid  as  a  vehicle  for  the  cocaine 
has  been  adopted  with  excellent  results  by  Morton  in  hundreds  of  cases.  To 
prevent  diffusion  a  viscid  substance,  such  as  glucose,  has  been  recommended. 


GENERAL     SURGICAL     CONSIDERATIONS  67 

This  is  quite  unnecessary,  although  theoretically  it  looks  attractive.  Such 
a  solution  forms  a  stratum  so  that  the  action  of  the  cocaine  is  concentrated 
at  one  point  and  being  of  greater  specific  gravity,  gravitates  to  the  most 
dependent  part  of  the  spinal  canal. 

The  use  of  adrenalin  retards  absorption  and  prolongs  anesthesia,  but 
does  not  prevent  diffusion  so  that  the  higher  centers  of  the  medulla  may 
become  affected. 

Points  of  Injection. 

The  region  in  which  the  spinal  puncture  is  to  be  made  should  be  as 
carefully  prepared  as  for  any  operation.  The  patient  is  placed  in  the  sitting 
posture  with  the  feet  hanging  over  the  side  of  the  bed,  or  if  unable  to  do 
this  he  should  be  placed  on  his  side  with  the  head  elevated.  For  this  pro- 
cedure a  good,  graduated  syringe  with  a  long  needle  and  stylet  are  required. 
The  needle  is  inserted  between  the  third  and  fourth,  or  the  fifth  and  sixth 
lumbar  vertebrae  between  the  spines  or  the  laminae.  The  former  is  pre- 
ferred, there  being  less  danger  of  injury  to  the  cauda  equina,  and  there  is 
less  liability  of  unilateral  anesthesia.  A  needle  with  the  opening  on  the  side 
is  to  be  preferred  so  that  as  soon  as  the  needle  enters  the  canal,  fluid  will 
appear.  As  soon  as  the  needle  enters  the  sac  the  stylet  is  removed  and  unless 
fluid  appears,  one  is  not  certain  that  he  is  in  the  spinal  canal.  Two  or  three 
cc.  of  fluid  are  removed  and  from  five  to  ten  cc.  of  a  one  per  cent,  solution 
are  injected.  The  strength  of  the  cocaine  solution  does  not  seem  to  play  a 
very  important  role  in  the  production  of  anesthesia.  Weak  solutions  act 
as  well  as  the  stronger  depending  on  the  pressure  from  the  larger  amount  of 
solution  used.  The  patient  is  placed  in  the  inclined  position  with  the  head 
elevated  according  to  the  height  of  the  anesthesia  required.  If  the  anesthe- 
sia is  unilateral,  he  is  gently  rolled  over  on  the  other  side.  Elevation  of  the 
head  is  very  important  in  order  to  prevent  anesthesia  of  the  higher  centers. 
The  head  should  not  be  lowered  for  several  hours  after  the  anesthesia  has 
disappeared. 

A  20  per  cent,  solution  of  magnesium  sulphate  has  been  recommended 
for  the  purpose  of  producing  spinal  anesthesia,  but  should  not  be  employed 
owing  to  the  alarming  symptoms  of  respiratory  depression  that  may  occur. 
When  injected  into  the  blood  sudden  death  may  result. 

Stovain  and  Strychnin. 

General  spinal  analgesia  by  the  use  of  stovain  and  strychnine,  accord- 
ing to  the  method  introduced  by  Jonnesco. 

This  plan  has  attracted  so  much  attention  that  it  seems  proper  to  de- 
scribe it  at  this  point,  although  it  has  not  as  yet  been  in  use  sufficiently  long 
to  be  so  thoroughly  established  as  to  make  it  proper  for  me  to  recommend 
its  use.  For  those  who  desire  to  test  this  method,  however,  the  following 
paragraphs  taken  from  Professor  Jonnesco's  article  in  the  British  Medical 
Journal,  Nov.  13,  1909,  give  each  step  precisely  as  practised  by  its  author, 
who  has  had,  of  course,  by  far  the  greatest  experience  in  this  direction  up 
to  the  present  time  and  who  considers  the  method  safe  as  compared  with 
others.  It  is  possible  that  the  striking  personality  of  this  surgeon  and 
his  enthusiasm  may  l:e  an  aid  in  the  results  obtained  by  him. 

Jonnesco's  Own  Description  of  Method. 

There  are  two  essential  points  of  novelty  in  the  method:  (1)  The  puncture  is 
made  at  a  level  of  the  spinal  column  appropriate  to  the  region  to  be  operated  upon; 


68  GENERAL    SURGICAL     CONSIDERATIONS 

(2)  anesthetic  solution  is  used  which,  thanks  to  the  addition  of  strychnine,  is  tolerated 
by  the  higher  nervous  centres.  The  selection  of  the  anesthetic  substance  to  be  used 
will  be  determined  by  the  surgeon's  experience  or  confidence  in  any  particular  drug. 
I  prefer  stovaine,  which  has  given  me  excellent  results,  and  which  I  know  how  to 
manage;  but  tropacocaine  or  novocain  are  equally  efficacious,  and,  thanks  to  the  addi- 
tion of  strychnine,  equally  harmless. 

1.  The  Preparation   of  the  Solution. — The   solution   must  be  made  at  the  time 
when  the  operation  is  to  be  performed  as  follows :    The  necessary  quality  of  stovaine. 
tropacocaine,  or  novocain  is  introduced  into  a  glass  tube  provided  with  an  india-rubber 
stopper,  and  sterilized  in  the  autoclave.     The  substances  need  not  be  sterilized  since 
they  are  themselves  antiseptic,  and  some  of  their  properties  would  be  destroyed  by 
heat. 

The  strychnine  solution  is  made  by  dissolving  5  to  10  eg.  of  neutral  strychnine 
sulphate  in  100  grams  of  sterilized  (not  distilled)  water  in  a  glass-stoppered  bottle 
previously  sterilized ;  if  5  eg.  of  strychnine  are  used  1  c.cm.  of  the  solution  will  con- 
tain Vz  mg. ;  if  10  eg.,  1  c.cm.  will  contain  1  mg.  The  weaker  solution  is  used  for  the 
upper,  the  stronger  for  the  lower  puncture.  As  the  strychnine  takes  some  time  to  dis- 
solve, it  is  better  to  prepare  this  solution  a  little  before  the  time  when  it  has  to  be 
used.  With  an  ordinary  Pravaz  syringe  provided  with  a  needle  for  lumbar  puncture. 
1  c.cm.  of  the  solution  of  strychnine,  a  syringeful,  is  drawn  up  and  is  injected  into 
the  tube  containing  the  dose  of  stovaine,  judged  to  be  necessary  for  the  puncture  about 
to  be  made.  The  tube  is  corked  again,  and  shaken,  and  the  salts  are  dissolved.  The 
same  syringe  is  then  filled  with  the  contents  of  the  tube,  and  is  held  with  a  sterilized 
compress  and  removed  from  the  needle  while  the  puncture  is  being  made. 

2.  The   Apparatus. — This,   as   has   already   been   indicated,   is   very   simple,   and 
within  the  reach  of  every  surgeon   in  all  circumstances,   since  it  consists  only  of  a 
common    Pravaz  syringe  holding  I   c.cm.,  and  the  usual  needle  for  lumbar  puncture 
previously  sterilized  by  boiling.     The  needle  I  prefer  has  a  point  cut  rather  squarely, 
for  since  the  arachnoid  space  is  relatively  small,  if  the  point  of  the  needle  be  oblique, 
it  is  possible  that  part  of  the  opening  might  go  through  the  dura  mater  while  part 
remained  outside  it.    If  this  occurs  part  only  of  the  solution  penetrates  into  the  arach- 
noid space,  while  a  greater  or  less  quantity  is  injected  into  the  space  between  the  dura 
mater  and  the  osseous  canal,  and  either  analgesia  is  not  produced  at  all,  or  it  is  in- 
complete; a  result  too  often  attributed  to  the  insufficiency  of  the  method  or  the  idio- 
syncrasy of  the  patient. 

3.  The  Puncture — In  my  communications  to  the  Congress  at  Brussels  and  to 
the  Academy  of  Medicine  in  Paris,  I  indicated  four  points  in  the  spine  at  which  the 
puncture  should  be  made  in  order  to  obtain  analgesia  of  the  region  to  be  operated 
upon.  I  had  already  been  convinced  by  experience  that  spinal  anesthesia  was  not  so 
regional  as  I  had  believed,  and  that  medio-cervical  puncture  was  as  useless  as  it  was 
dangerous.  It  favors  the  appearance  of  bulbar  phenomena — nausea,  vomiting,  pallor 
of  the  face,  faintness,  momentary  stoppage  of  respiration,  and  so  on,  phenomena  due 
to  a  too  direct  action  of  Lhe  anesthetic  fluid  upon  the  bulb.  Their  occurrence  may  be 
avoided  by  making  the  puncture  lower  down  between  the  first  and  second  dorsal  ver- 
tebrae, which  produces  as  perfect  and  deep  analgesia  for  the  segment  of  the  body  com- 
prising the  head,  neck,  and  upper  limbs  as  is  produced  by  medio-cervical  puncture. 
Medio-dorsal  puncture  between  the  seventh  and  eighth  dorsal  vertebras  is  very  often 
difficult  to  perform,  and  is  not  necessary,  for  perfect  analgesia  of  the  lower  segment 
of  the  thorax  can  be  obtained  by  puncture  made  between  the  last  dorsal  and  first 
lumbar  vertebras,  which  is  easier  to  perform  and  produces  also  anesthesia  of  the  whole 
lower  part  of  the  body. 

I  have  therefore  reduced  sites  of  election  for  puncture  to  two — namely: 

(a)  Upper  Dorsal  Punctu-re. — Upper  dorsal  puncture  between  the  first  and  second 
dorsal  vertebrae  is  easily  performed;  the  landmark  is  the  vertebra  prominens  with  the 
visible   and  tangible   protuberances   of  the   spinous  processes  of   the  second  and  third 
dorsal  vertebrae.     When  the  patient's  head  is  strongly  flexed,  so  that  the  chin  touches 
the  sternum,  the  protuberances  are  very  marked,  and  the  spaces  they  bound  are  en- 
larged.    The  patient  being  placed   in  this  position,  the   surgeon  marks  with  the  fore- 
finger of  his  left  hand  the  space  between  the  first  and  second  dorsal  vertebras,  and 
the   needle,   held   between   the   thumb   and    forefinger   and   middle   finger   of   the   right 
hand,  is  pushed  in,  following  the  upper  border  of  the  spinous  processes  of  the  second 
dorsal  vertebras.     For   operations   on   the   head,   neck,  upper   limbs,   and    thorax    the 
puncture  snould  be  made  in  this  situation. 

(b)  The    Dorso-Lumbar    Puncture. — The    dorso-lumbar    puncture     between     the 


GENERAL    SURGICAL     CONSIDERATIONS  69 

twelfth  dorsal  and  first  lumbar  vertebrae  is  very  easily  made,  owing  to  the  large  space 
which  separates  the  two  spinous  processes.  I  prefer  this  puncture  to  the  classical 
lumbar  puncture  between  the  third  and  fourth  lumbar  vertebrae,  because  it  produces 
more  perfect  analgesia  of  the  whole  abdomen  and  lower  segment  of  the  body.  The 
space  is  easily  found,  for  it  is  necessary  only  to  count  the  lumbar  spines  upwards. 
The  patient  is  seated  with  the  thorax  bent  strongly  forward,  as  in  ordinary  lumbar 
puncture.  In  making  the  puncture,  the  forefinger  of  the  left  hand  marks  the  space, 
while  the  needle  is  pushed  in  with  the  right  hand,  following  the  upper  border  of  the 
underlying  spinous  process. 

In  both  cases  the  puncture  is  made  in  the  median  plane.  Once  the  resistance  of 
the  skin  has  been  surmounted,  the  needle  must  be  pushed  forward  slowly,  so  as  not 
to  tear  the  tissues  which  are  being  transfixed.  As  a  rule  the  needle  enters  easily  as 
far  as  the  dura  mater,  when  a  momentary  resistance  is  felt ;  when  this  has  been  over- 
come, the  flow  of  spinal  fluid  shows  that  the  needle  is  in  the  right  space.  When  the 
puncture  is  made  at  the  high  dorsal  level,  where  the  pressure  of  the  cerebro-spinal 
fluid  is  diminished,  it  comes  out  drop  by  drop,  whereas  in  the  dorso-lumbar  puncture 
it  spurts  out  in  a  stream.  This  is  the  rule,  but  there  are  exceptions,  for  sometimes 
in  the  high  dorsal  puncture  no  fluid  escapes ;  an  effort  of  coughing  will  then  usually 
suffice  to  make  it  appear,  although  it  may  be  necessary  to  adapt  a  sterilized  syringe 
to  the  needle  in  order  to  aspirate  the  fluid.  If  no  fluid  is  thus  obtained,  the  surgeor 
must  conclude  that  his  needle  is  not  in  the  arachnoid  cavity;  the  point  of  the  needle 
must  be  disengaged,  drawn  back  slightly,  and  pushed  in  again  until  the  space  is  found. 
If  the  needle  is  introduced  obliquely  it  may  impinge  on  a  lamina,  but  the  peculiar  sen- 
sation of  having  touched  bone  will  warn  the  surgeon ;  he  must  then  withdraw  the 
needle  completely  and  reintroduce  it  in  the  proper  way — namely,  in  the  median  plane. 
If  the  fluid  which  escapes  is  blood-stained,  it  shows  that  a  small  vein  has  been  trans- 
fixed— a  matter  of  no  importance,  since  the  hemorrhage  will  soon  cease  spontaneously 
and  the  fluid  become  clear. 

It  is  also  possible  to  make  the  punctures  with  the  patient  lying  on  his  right  side, 
the  head  beinpp  strongly  bent  on  the  chest  for  the  high  dorsal  puncture,  and  the  thorax 
being  bent  forward  for  the  dorso-lumbar  puncture.  This  position  should  be  pre- 
ferred when  the  patient  is  feeble  or  very  impressionable  and  cannot  remain  in  the  sit- 
ting position  without  risk  of  fainting;  it  must  also  be  used  if,  an  operation  having 
lasted  longer  than  was  anticipated,  a  second  puncture  and  injection  to  prolong  the 
analgesia  becomes  necessary. 

4.  The  Injection.— As  soon  as  the  escape  of  cerebro-spinal  fluid  renders  it  cer- 
tain that  the  arachnoid  space  has  been  entered,  its  further  loss  should  be  stopped,  for 
I  am  convinced  that  the  escape  of  more  than  a  certain  quantity  of    fluid   is  rather 
harmful  than  useful.     The  loss  of  too  much  fluid   (1)   may  cause  signs  of  faintness, 
pallor  of  the   face,  sweating,  etc.;   and   (2)    by  suddenly  diminishing  the  quantity  of 
cerebro-spinal  fluid  may  cause  too  rapid  diffusion  of  the  anesthetic,  which  is  unde- 
sirable and  may  be  mischievous.     As  soon,  then,  as  a  few  drops  of  fluid  have  escaped, 
the   needle   is   closed  with   the   forefinger   of  the   left   hand,  while   with   the   right   the 
syringe  filled  with  the  anesthetic  mixture  is  adapted  to  the  needle.     The  liquid  must 
be  slowly  injected  so  as  not  to  produce  an  undue  impact  upon  the  spinal  cord. 

5.  Position   of   Patient   after  Injection. — The   position   to   be   assumed    by    the 
patient  after  the  injection,  so  as  to  ensure  analgesia  of  the  region  to  be  operated  upon, 
is  a  cardinal  point,  for  by  attention  to  it  we  can   favor  the  distribution  of  the  liquid 
in  the  desired  direction.     If  with   the  higher  dorsal   injection   it  is   desired  to   obtain 
analgesia  of  the  head  and  neck,  the  patient  is  made  to  lie  on  his  back;  if  the  operation 
is  to  be  on  the  throat,  the  head  should  be  a  little  raised ;  if  on  the  face  or  skull,  he 
should  lie  horizontally;   if  on  the  upper  limb  or  the  thorax,  he  should  remain  sitting 
for  two  or  three  minutes,  and  then  lie  on  the  back  with  the  head,  neck  and  thorax 
bent   slightly   forward.      If   after   four   or   five   minutes   the   analgesia   of   the   head   or 
of  the  neck  is  not  complete,  the  patient's  head  should  be  lowered  below  the  level  of  the 
body  for  three  or  four  minutes. 

With  dorso-lumbar  injection  if  the  viscera  of  the  upper  abdominal  region  (liver, 
stomach,  spleen,  pancreas,  kidneys,  etc.)  are  to  be  operated  upon,  the  patient  must 
remain  in  the  sitting  posture  for  two  or  three  minutes,  and  then  lie  on  the  back,  the 
head,  neck,  and  shoulders  being  raised.  If  after  five  or  six  minutes  the  analgesia  is 
incomplete,  the  patient  must  be  inclined  (Trendelenburg)  for  a  few  minutes,  three 
or  four,  after  which  he  again  returns  to  the  sitting-  posture.  If  the  operation  is  on 
the  lower  abdominal  region  (pelvis,  perineum,  external  genital  organs)  or  on  the 
lower  limbs,  the  patient  should  remain  in  the  sitting  posture  for  five  or  six  minutes, 


70  GENERAL    SURGICAL     CONSIDERATIONS 

and  then  lie  on  his  back,  with  the  upper  part  of  the  body,  head,  neck,  and  thorax 
raised  and  bent  forward. 

6.  The  Dose. — The  amount  of  stovaine  and  strychnine  in  the  anesthetic  mixture 
should  vary  with  the  site  of  the  injection,  the  patient's  age,  and  his  general  condition. 
I  confine  my  remarks  to  stovaine,  as  it  is  the  drug  with  which  long  practice  has  made 
me  familiar,  so  that  I  can  administer  it  with  precision  and  safety.  I  cannot  speak 
with  equal  confidence  of  other  anesthetics,  such  as  novocain  and  tropacocaine,  with 
which  I  have  had  little  experience. 

Strychnine. — The  variation  in  the  quantity  of  strychnine  is  not  relatively  great. 
For  the  higher  dorsal  injection  I  employ:  For  children  of  from  1  to  5  years  %  mg. 
in  1  c.cm.  The  solution  is  made  by  dissolving  3%  eg.  of  neutral  strychnine  sulphate 
in  100  grams  of  sterilized  water.  For  children  above  5  years,  for  adolescents,  adults, 
and  aged  people  the  solution  contains  V-z  mg.  of  neutral  strychnine  sulphate  in  1  c.cm., 
and  is  made  by  dissolving  5  eg.  of  the  strychnine  salt  in  100  grams  of  sterilized  water. 
For  dorso-lumbar  injection,  for  children  from  1  to  10  years  old,  I  use  a  solution  con- 
taining 1  mg.  of  strychnine  in  1  c.cm. ;  for  children  above  10  years,  adolescents,  adults, 
and  old  people,  a  solution  containing  1  mg.  in  1  c.cm.,  made  by  dissolving  10  eg.  of 
the  neutral  strychnine  sulphate  in  100  grams  of  sterilized  water. 

Stovaine. — The  amount  of  stovaine  varies  with  the  site  of  the  injection,  the 
patient's  are,  and  his  general  condition.  For  the  higher  dorsal  injection  I  use  for 
children  from  1  to  5  years  old,  1  eg. ;  from  5  to  15  years,  2  eg. ;  for  adolescents,  adults, 
and  aged  people,  3  eg.  For  the  dorso-lumbar  puncture,  for  children  from  1  to  5 
years,  2  to  3  eg. :  from  5  to  15  years,  4  to  6  eg.;  for  adolescents  from  15  to  20  years 
old,  6  to  8  eg. ;  and  for  adults  and  aged  people  10  eg.  The  dose  of  stovaine  must  also 
be  adapted  to  the  general  condition  of  the  patient.  In  persons  who  are  consumptive, 
very  anemic,  who  are  suffering  from  auto-intoxication  or  grave  infections,  or  who 
have  suffered  severe  injury,  or  are  ischemic  owing  to  profuse  hemorrhage,  5  or  6  eg. 
of  stovaine  produce  deep  and  prolonged  analgesia,  and  larger  doses  are  badly  tol- 
erated, causing  pallor  of  the  face,  nausea,  vomiting  and  transient  faintness. 

In  order  to  be  able  to  judge  of  the  degree  of  the  diffusibility  of  the  liquid  in- 
jected :nto  the  arachnoid  cavity  the  specific  gravity  of  the  solution  of  strychnine  and 
sto^aine  compared  with  that  of  the  cerebro-spinal  fluid  must  be  known.  The  average 
density  of  cerebro-spinal  fluid  is  1,003,  but  it  varies  from  1,003  to  1,020.  Dr.  Hancu, 
Chief  Pharmacist  to  the  Coltza  Hospital,  has  found  that  the  following  solutions  have 
the  specific  gravity  stated  : 

Grains.  Sp.  gr. 

1.  Strychnine    0.05 

Stovaine    2.00         1,0019 

Water    100.00 

2.  Strychnine    0.05 

Stovaine    3.00         1,0030 

Water    100.00 

3.  Strychnine    0.10 

Stovaine    6.00         1,0071 

Water    1 00.00 

4.  Strychnine    0.10 

Stovaine    8.00         1,0105 

Water    100.00 

5.  Strychnine    0.10 

Stovaine    10.00         1,0120 

Water    100.00 

The  solution  used  for  injection  in  high  dorsal  puncture  (containing  3  eg.  of  sto- 
vaine and  Vz  mg.  of  strychnine)  has  a  specific  gravity  equal  to  or  greater  than  the 
average  density  of  cerebro-spinal  fluid;  this  fact  explains  the  rapid  diffusion  towards 
the  cervical  part  of  the  cord  and  the  cranial  cavity,  which,  as  will  be  shown  later, 
takes  place  if  the  injection  is  made  here,  and  also  the  readiness  with  which  analgesia 
is  produced.  The  solution  used  for  injection  in  the  dorso-lumbar  puncture  has,  on 
the  other  hand,  a  specific  gravity  greater  than  that  of  cerebro-spinal  fluid,  and  the 
larger  the  quantity  of  stovaine  the  higher  the  specific  gravity.  In  this  situation  the 


GENERAL    SURGICAL     CONSIDERATIONS  ~l 

diffusion  of  the  solution  takes  place  slowly,  a  fact  which  explains  the  relative  delay 
in  the  production  of  the  analgesia,  and  partly  also  the  harmlessness  of  the  Trendelen- 
burg  position,  the  solution  tending  to  remain  in  the  lower  parts  of  the  arachnoid  cavity. 

Phenomena  Observed  During  Analgesia. — With  the  higher  dorsal  puncture  the 
analgesia  is,  for  the  reason  just  stated,  usually  complete  in  two  or  three  minutes.  On 
the  other  hand,  after  dorso-lumbar  injection,  analgesia  is  produced  more  slowly,  but 
is  complete  in  at  most  ten  minutes.  If  analgesia  is  not  obtained  within  this  time,  it  is 
evidence  that  the  solution  has  not  reached  the  arachnoid  cavity,  or  has  reached  it  in 
too  small  a  quantity,  and  the  puncture  and  injection  must  be  repeated.  It  is  a  mistake 
to  attribbute  failure  to  produce  analgesia  to  idiosyncrasy.  It  is  true  that  I  have  seen 
some  cases  in  which  after  puncture  followed  by  a  flow  of  cerebro-spinal  fluid  no 
analgesia  has  been  produced,  but  a  second,  or  in  some  cases  a  third  injection  of  the 
same  dose  of  the  anesthetic  has  produced  complete  analgesia.  It  is  tempting  to  sup- 
pose that  these  patients  were  refractory  to  normal  doses  and  required  larger  doses, 
but  this  is  a  mistake ;  no  patient  could  support  20  to  30  eg.  of  stovaine  and  2  or  3  mg. 
of  strychnine  without  presenting  marked  bulbar  phenomena — stoppage  of  breathing 
and  of  the  heart — attributable  to  the  excess  of  stovaine.  The  occurrence  must  be 
otherwise  explained.  It  is  to  be  attributed  to  an'  untimely  movement  of  the  patient 
at  the  moment  of  the  injection,  very  trifling,  perhaps,  in  appearance,  but  sufficient  to 
displace  the  point  of  the  needle  already  engaged  in  the  arachnoid  cavity.  Owing  to  the 
slight  and  imperceptible  displacement  the  orifice  of  the  needle  is  withdrawn  partly  or 
wholly  from  the  cavity,  and  the  solution  is  therefore  injected  in  part  or  in  whole  out- 
side the  cavity,  between  the  dura  mater  and  the  osseous  canal. 

In  one  case  of  high  dorsal  puncture  I  only  obtained  analgesia  after  a  third  in- 
jection— that  is  to  say,  after  using  9  eg.  of  stovaine  and  l1/^  mg.  of  strychnine,  doses 
which  no  patient  could  support  without  showing  bulbar  phenomena.  It  is  certain, 
therefore,  that  only  the  third  injection  penetrated  the  arachnoid  cavity.  In  another 
case  of  dorso-lumbar  injection,  in  a  patient  in  whom  on  a  previous  occasion  excellent 
analgesia  was  obtained  with  6  eg.  of  stovaine,  16  eg.  in  two  injections  failed  to  give 
any  result,  and  it  was  only  after  a  third  injection  of  6  eg.  that  analgesia  was  produced. 

During  analgesia  patients  retain  full  consciousness,  and  I  am  in  the  habit  of 
speaking  to  them  to  divert  their  attention  from  the  operation,  of  which  the  majority 
are  unaware,  the  operating  field  being  hidden  from  them  by  a  cloth  supported  by  two 
bars  attached  to  the  operating  table  at  the  level  of  the  neck.  I  prefer  this  cloth  to  a 
mask,  which  is  embarrassing  to  the  patient  and  a  great  trial  to  his  patience  during  a 
long  operation.  A  patient  may  be  heard  to  ask  after  an  operation  is  finished  when  it 
is  to  be  begun. 

The  immobility  of  the  limbs,  the  neck,  and  the  head,  due  to  paresis  caused  by  the 
spinal  analgesia,  is  a  great  advantage  to  the  surgeon  by  suppressing  movements  which 
might  embarrass  him.  It  is  true  that  there  may  be  complete  anesthesia  without  loss 
of  mobility  in  the  limbs ;  this  rarely  happens,  but  its  occurrence  ought  to  be  known, 
as  it  is  not  necessary  to  wait  for  paresis  before  beginning  to  operate. 

After  dorso-lumbar  injection  the  abdominal  viscera,  including  the  intestines,  are 
immobile,  and  this  "abdominal  stillness"  is  a  great  advantage,  especially  in  gynecolog- 
ical laparotcmies.  The  viscera  are,  as  it  were,  congealed,  are  not  stimulated  by  any 
fit  of  coughing  or  effort  of  vomiting,  and  therefore  do  not  obstruct  the  field  of  opera- 
tion, as  happens  so  often  with  inhalation  anesthesia. 

The  occurrence  of  such  phenomena  as  pallor  of  the  face,  nausea,  or  sweating, 
so  often  observed  when  spinal  analgesia  is  produced  by  the  injection  of  stovaine,  tropa- 
cocaine,  or  novocain  is  seen  only  exceptionally  when  the  stovaine  and  strychnine  solu- 
tion is  used.  The  face  retains  its  normal  aspect ;  nausea  occurs  in  2.25  per  cent ; 
vomiting — a  single  effortless  ejection — in  1.25  per  cent;  and  sweating  in  2  per  cent. 
In  some  cachectic,  feeble  individuals  I  have  observed  fecal  incontinence  (4  per  cent). 
The  pulse,  which  is  slowed  in  spinal  analgesia  produced  by  stovaine  alone,  is,  when 
the  stovaine  and  strychnine  solution  is  used,  usually  normal  in  rapidity  and  strength. 
Sometimes  it  rises  to  80  to  90,  but  always  remains  strong.  These  facts  prove  the  pow- 
erful influence  of  the  strychnine  in  neutralizing  the  depressing  action  of  the  stovaine. 
Under  certain  special  conditions  I  have  in  5  cases  observed  momentary  stoppage  of 
respiration  ;  in  3  of  these  cases  I  had  used  for  medio-cervical  puncture  a  solution  to 
which  atropine  %  mg.  had  been  added.  I  have  abandoned  both  the  use  of  atropine 
and  puncture  in  this  situation.  In  one  other  case  I  had  used  for  high  dorsal  injection 
4  eg.  of  stovaine,  too  large  a  dose,  as  subsequent  experience  has  proved.  In  the  fifth 
case  dorso-lumbar  puncture  had  been  preceded  by  subcutaneous  injection  three  and  a 
half  hours  before  operation  of  scopolamin  and  morphine.  In  this  case,  as  I  had 


72  GENERAL    SURGICAL    CONSIDERATIONS 

feared  in  view  of  the  poisonous  effects  of  so  powerful  a  drug  as  scopolamin,  the  respi- 
ration stopped,  and  was  only  re-established  after  fifteen  minutes.  None  of  these 
accidents  can  be  attributed  to  the  method  that  I  have  here  described,  but  to  departures 
from  it  which  ought  to  be  avoided. 

Duration  of  Analgesia. — The  analgesia,  when  the  anesthetic  is  administered  in 
the  manner  described,  lasts  from  one  and  a  half  to  two  hours,  a  period  longer  than  is 
necessary  to  perform  any  operation.  I  should  add  for  the  benefit  of  surgeons  inexperi- 
enced in  spinal  analgesia,  that  though  the  condition  may  be  obtained  with  less  than  3 
eg.  of  stovaine  in  high  dorsal  puncture,  and  less  than  10  eg.  in  the  dorso-lumbar  punc- 
ture, the  anesthesia  is  neither  so  deep  nor  so  durable.  With  8  eg.  analgesia  may  be 
produced,  but  the  patient  preserves  sensation  of  contact  and  of  traction  on  the  viscera, 
or  on  the  sides  of  the  wound.  With  10  eg.  all  sensation  is  abolished;  for  this  reason 
there  should  be  no  hesitation  in  using  doses  which  may  seem  large  but  which  are 
harmless  and  produce  complete  anesthesia.  If  an  operation  has  lasted  so  long  that 
the  analgesia  passes  off,  I  make  another  puncture  with  the  patient  in  dorsal  decubitus, 
and  in  this  way  analgesia  can  be  prolonged  as  long  as  may  be  necessary  without  incon- 
venience. This  dose  used  for  the  second  injection  should  be  either  equal  to  that  given 
in  the  first  or  smaller,  according  to  the  probable  duration  of  the  operation. 

Phenomena  After  Analgesia. — Headache,  retention  of  urine,  and  a  rise  of  tem- 
perature, frequently  observed  when  spinal  analgesia  is  produced  by  stovaine  alone,  are 
seldom  noted,  and  are  of  short  duration  when  the  method  here  described  is  followed. 
Headache  has  been  observed  in  6.25  per  cent,  but  is  not  severe  and  disappears  in  a 
few  hours.  Transitory  retention  of  urine  was  observed  in  4.5  per  cent,  but  only  in 
those  operations  in  which  it  is  also  produced  with  inhalation  anesthesia,  such  as  those 
on  the  anus,  the  uterus,  and  for  hernia.  In  no  case  did  the  temperature  reach  40°  C. 
(104°  F.)  ;  a  temperature  as  high  as  39°  C.  (102.2°  F.)  was  observed  on  the  evening 
of  the  day  of  operation  in  1.75  per  cent;  of  38°  C.  (100.4°  F.)  in  16  per  cent;  of  37°  C. 
(98.6°  F.)  in  50  per  cent.  Post-operative  vomiting  has  rarely  been  observed,  and  I 
have  never  seen  post-analgesic  paralysis. 

Conclusions. — 1.  The  fundamental  principles  in  spinal  analgesia  are  that  punc- 
ture of  the  arachnoid  may  be  performed  at  all  levels,  and  that  to  the  anesthetic, 
whether  stovaine,  tropacocaine,  or  novocain,  strychnine  should  be  added. 

2.  Puncture  of  the  arachnoid  at  whatever   level  is  harmless,  and  the   fear  of 
pricking  the  cord  unfounded;  even  if  it  happens  it  is  not  harmful. 

3.  Medio-cervical  puncture  is  useless  and  dangerous;  mid-dorsal  puncture  is  diffi- 
cult and  useless ;  superior  dorsal  puncture  between  the  first  and  second  dorsal  vertebrae, 
and  dorso-lumbar  between  the  last  dorsal  and  first  lumbar  vertebrae  are  easy,  and  suf- 
fice to  obtain  analgesia  of  all  regions  of  the  body. 

4.  The  addition  of  neutral  strychnine  sulphate  to  the  anesthetic  preserves  the 
full  antiseptic  power  of  the  solution  and  at  the  same  time  neutralizes  its  injurious  ac- 
tion upon   the  bulb.     Thanks  to  this  addition,   superior  spinal  analgesia  can  be  per- 
formed without  danger. 

5.  Among   known    anesthetic    substances,   stovaine,   tropacocaine,    and    novocain 
seem  to  be  the  best ;  any  of  them  may  be  used  with  the  addition  of  strychnine. 

6.  The  strychnine  and  the  anesthetic  substance  need  not  be  sterilized,  a  process 
which  would  destroy  some  of  their  properties. 

7.  The  water  used  for  making  the  solution  must  be  sterilized  but  not  distilled. 

8.  The  injection  should  consist  of  1  c.cm.  of  solution,  the  amount  of  strychnine 
and  anesthetic  substance  being  varied. 

9.  The  technique  is  simple,  requiring  only  a  Pravaz  syringe  and  the  usual  needle 
for  lumbar  puncture. 

10.  There  are  no  contraindications  for  general  spinal  anesthesia,  which  always 
succeeds  if  the  liquid  penetrates  into  the  arachnoid  cavity  and  if  the  dose  of  the  an- 
esthetic is  sufficient. 

11.  General  spinal  anesthesia  is  absolutely  safe;  it  has  never  caused  death,  nor 
produced  any  important  complications,  early  or  late. 

12.  General  spinal  anesthesia  is  infinitely  superior  to  inhalation  anesthesia.     Ow- 
ing to  its  simplicity,  it  is  within  the  reach  of  all,  and  as  there  is  no  contraindication  it 
may  be  employed  with  any  patient.     As  it  can  be  performed  by  the  surgeon  himself  it 
does  away  with  the  attend'ance  of  a  person  often  inexperienced,  and  never  responsible. 

13.  In   operations   on   the   face,   or  the   throat,   where   analgesia  by  inhalation   is 
difficult  and  often  incomplete,   spinal  analgesia  is  a  great  resource.     In  laparotomies, 
owing  to  the  "abdominal  silence"  it  determines,  it  is  very  much  superior  to  analgesia 
bv  inhalation. 


GENERAL     SURGICAL     CONSIDERATIONS  73 

14.  The   facts  stated  in  this  paper  will  prove  how  in  science  a  condemnation 
a  priori  like  that  pronounced  by   Professors   Bier  and   Rehn   is  precipitate   and   ill- 
founded. 

15.  I  am   firmly  convinced  that  general   spinal   analgesia  will  be  the  analgesic 
method  of  the  future. 

Ethyl  Chloride. 

This  substance  is  very  volatile  and  when  applied  to  the  skin  evaporates 
rapidly,  producing  a  great  amount  of  cold.  As  a  general  anesthetic  its  use 
is  limited  to  short  operations  and  except  in  the  hands  of  an  expert  it  is  as- 
sociated with  great  danger.  Its  advantages  over  ether  are  the  brief  period 
of  excitation,  the  prompt  return  to  consciousness,  and  the  absence  of  dis- 
agreeable after  affects.  Locally,  it  can  only  be  used  where  a  single  incision 
is  required  and  for  the  introduction  of  aspirating  or  transfusion  needles. 
It  is  sponged  upon  the  surface  until  the  skin  is  frozen  into  a  hard  white 
mass,  then  the  slight  operation  is  performed  before  the  heat  of  the  body  and 
the  temperature  of  the  room  have  thawed  out  the  frozen  skin.  The  after- 
pain  is  rather  more  severe  than  in  case  of  general  anesthesia,  but  as  the 
wounds  are  always  small,  this  is  of  no  great  importance. 

A  Ready  Freezing  Mixture. 

The  same  end  can  be  accomplished  by  placing  equal  parts  of  chipped 
ice  and  table-salt  in  a  piece  of  sterile  gauze  of  about-  four  thicknesses  and 
holding  this  for  about  one  minute  directly  upon  the  area  which  is  to  be  in- 
cised or  punctured.  This  will  freeze  the  skin  quite  as  effectively  as  the 
ethyl  chloride  spray.  The  gauze  may  be  moistened  with  a  one  to  2,000 
solution  of  corrosive  sublimate  in  order  to  ensure  antiseptic  conditions.  This, 
however,  is  not  necessary,  because  clean  table-salt  and  clean  ice  are  both 
sufficiently  free  from  pathogenic  micro-organisms  to  make  their  use,  as  de- 
scribed above,  safe. 

Scopolamin  and  Morphin. 

We  are  firmly  convinced  that  the  use  of  scopolamin  with  morphin  for 
the  purpose  of  anesthesia  is  to  be  warned  against.  It  is  a  very  powerful 
drug  combination,  different  preparations  of  which  vary  in  activity.  Con- 
fusion and  violent  delirium  may  follow  its  administration.  We  have  employed 
this  method  sufficiently  often  to  be  convinced  that  it  is  much  more  dangerous 
than  ether  anesthesia  by  the  drop  plan.  In  cases  in  which  it  seems  indicated, 
we  greatly  prefer  to  give  morphine,  one-sixth  to  one-third  grain,  with  atro- 
pine  one  one-hundred  and  fiftieth  to  one-hundredth  grain,  hypodermically, 
half  an  hour  before  beginning  the  administration  of  the  anesthetic. 

Various  modifications  of  the  original  plan  of  using  scopolamin  and 
morphine  have  been  suggested  and  other  drugs  like  hyoscin  have  been 
substituted,  but  the  effect  is  the  same.  If  used  in  small  quantities  they  seem 
no  more  efficient  than  morphine  alone,  and  when  used  in  large  quantities 
they  appear  much  more  dangerous. 

RECTAL  ANESTHESIA. 

The  advantage  of  this  method  must  be  apparent  if  further  experience 
does  not  show  harmful  effects. 

Advantages  Claimed. 

The  following  advantages  are  claimed  by  those  who  have  employed  it. 


74  GENERAL     SURGICAL     CONSIDERATIONS 

1.  The  amount  of  ether  used  is  very  much  smaller  than  by  inhalation 
method. 

2.  There  is  no  stage  of  excitation. 

3.  There  is  no  irritation  of  the  respiratory  mucous  membranes. 

4.  The  anesthetist  does  not  approach  the  field  of  operation. 

5.  Besides  being  out  of  the  way  he  also  is  unable  to  infect  the  wgund. 

6.  The  patient  awakens  almost  at  once  after  the  anesthetic  is  stopped. 

7.  There  is  said  to  be  less  nausea  and  vomiting,  probably  because  the 
patient  has  not  swallowed  quantities  of  mucus  saturated  with  ether. 

8.  There  is  no  depressing  effect  upon  the  heart. 

It  is,  however,  to  be  remembered  that  all  of  these  advantages  are  also 
obtained  if  the  method  is  employed  which  has  just  been  described  of  thor- 
oughly anesthetizing  the  patient  by  inhalation  and  then  stopping  the  anes- 
thetic and  elevating  the  head  during  the  operation. 
Method  of  Application. 

It  is  in  the  first  place  most  important  that  the  colon  be  empty  at 
the  time  of  administration  of  ether  by  rectum,  because  the  presence  of  feces 
will  prevent  the  rapid  absorption  of  ether  and  the  openings  in  the  tube 
through  which  the  ether  fumes  are  introduced  may  become  clogged  and  thus 
the  introduction  in  sufficient  quantities  of  the  anesthetic  may  be  prevented. 

In  order  to  secure  an  empty  colon  two  ounces  of  castor  oil,  preferably 
in  beer  foam,  should  be  given  twenty-four  hours  before  the  operation ; 
twelve  hours  later  the  patient  should  receive  a  large  cleansing  enema  of 
soap  suds  and  normal  salt  solution  and  this  enema  should  be  repeated  three 
hours  before  the  operation.  In  the  meantime  no  food  should  be  given 
except  broths  and  gruels,  in  order  that  there  may  not  be  any  fresh  intes- 
tinal accumulation. 

The  patient  is  placed  upon  the  table,  the  surface  of  the  neck  thoroughly 
prepared  and  then  covered  with  a  piece  of  sterile  gauze  saturated  with  alco- 
hol. The  hair  is  covered  and  a  gauze  pad  is  placed  across  the  mouth  and 
nose  as  described  previously,  in  fact  the  preliminary  preparation  is  identical 
with  that  employed  if  the  operation  is  to  be  performed  under  ether  anesthesia 
by  inspiration.  An  assistant  also  draws  the  lower  jaw  forward  and  holds 
it  in  that  position  throughout  the  operation. 

An  ordinary  soft  rubber  rectal  tube  with  an  opening  at  the  end  is  then 
slowly  introduced  into  the  rectum  a  distance  of  eight  or  ten  inches.  The 
tube  should  be  thoroughly  lubricated  in  order  to  prevent  annoyance  by 
friction.  The  gas  contained  in  the  rectum  is  thus  permitted  to  escape  in 
order  to  facilitate  the  absorption  of  ether.  The  rectal  tube  is  then  attached 
to  the  tube  through  which  the  ether  fumes  are  pumped  into  the  rectum.  The 
colon  is  then  slowly  filled  with  ether  fumes  and  then  the  rectal  tube  is  once 
more  disconnected  in  order  that  any  remaining  intestinal  gas  which  was  not 
evacuated  primarily  may  escape.  This  procedure  may  be  repeated  several 
times,  care  being  taken  that  the  ether  fumes  are  not  injected  too  rapidly  for 
fear  of  too  great  distension  or  irritation.  At  first  some  gas  may  escape  along 
the  side  of  the  rectal  tube,  but  this  can  soon  be  prevented  by  injecting  only 
just  enough  gas  to  fill  the  colon.  There  may  be  slight  colicky  pains  at  first. 
but  the  patient  will  soon  become  accustomed  to  the  sensation.  If  the  castor 
oil  and  the  enema  have  acted  satisfactorily,  there  will  be  no  annovance  from 
defecation  or  clogging  of  the  rectal  tube.  The  full  anesthesia  will  occur  in 


GENERAL     SURGICAL     CONSIDERATIONS  75 

from  five  to  fifteen  minutes,  and  the  operation  can  be  performed  with  the 
consumption  of  from  one  to  three  ounces  of  ether. 

When  the  operation  is  completed  to  the  point  of  suturing  the  external 
wound,  the  apparatus  is  detached  from  the  rectal  tube  and  the  accumulated 
gas  in  the  colon  will  thus  be  permitted  to  escape.  If  the  patient  is  slightly 
consc.^us  of  the  application  of  the  skin  sutures,  the  consequent  deep 
breat'  'g  v  11  facilitate  the  excretion  of  most  of  the  ether  contained'  in  the 
blood  through  expired  air.  It  also  facilitates  the  expulsion  of  any  ether 
fumes  which  may  still  remain  in  the  colon.  This  can  be  further  favored  by 
making  gentle  abdominal  massage. 

The  patient  must  be  observed  throughout  the  period  of  administration 
with  the  same  care  as  when  ether  is  given  through  the  respiratory  tract. 
Cyanosis  will  almost  never  occur  if  the  lower  jaw  is  held  forward  as  stated. 
The  pulse  and  respiration  \vill  indicate  the  progress  of  the  anesthesia.  It  is 
rarely  necessary  to  disconnect  the  rectal  tube  from  the  apparatus  and  to 
make  abdominal  massage  to  force  the  ether  fumes  out  of  the  rectum  during 
the  operation,  but  in  case  of  necessity  this  could  be  readily  done.  If  the 
head  is  elevated  after  the  operation  is  begun,  almost  no  anesthetic  will  be 
required  during  the  actual  progress  of  the  operation. 

Apparatus. 

Various  forms  of  containers  have  been  invented  for  producing  the  ether 
fumes  utilized  in  this  form  of  anesthesia.  A  simple,  deep  bottle  constructed 
on  the  general  plan  of  wash  bottles  used  in  chemical  laboratories  seems  to 
suffice  perfectly  if  mounted  on  a  stand  which  can  be  easily  moved  without 
breaking  the  bottle  or  its  attachments.  The  bottle  should  be  fitted  with  a 
rubber  stopper  with  two  holes,  one  of  which  contains  a  glass  tube  whose 
lower  end  is  even  with  the  stopper  and  whose  upper  end  is  attached  to  a 
rubber  tube  which  in  its  turn  is  fastened  to  a  glass  tube  for  attachment  to 
the  rectal  tube.  The  other  hole  contains  a  glass  tube  with  bulb-shaped 
lower  end  containing  many  small  perforations  and  reaching  to  the  bottom 
of  the  bottle.  The  upper  end  of  this  tube  projects  through  the  upper  sur- 
face of  the  rubber  stopper  a  sufficient  distance  to  permit  the  attachment  of 
a  rubber  tube  the  other  end  of  which  is  attached  to  a  bulb  with  which  air 
can  be  forced  into  the  bottle.  The  bottle  should  be  at  least  thirty  centi- 
meters deep  so  that  the  air  can  be  forced  through  a  considerable  column 
of  ether.  The  bottle  is  filled  with  ether  to  a  point  five  cm.  from  the  lower 
surface  of  the  cork,  the  upper  portion  of  the  bottle  being  left  as  a  gas 
space. 

This  bottle  should  be  immersed  in  a  vessel  containing  water  at  a  tem- 
perature of  from  80  to  loo  degrees  F.,  according  to  various  clinicians,  the 
boiling  point  of  ether  being  98.8  degrees  F.  A  thermometer  is  to  be  placed 
in  the  water  and  a  stopcock  at  the  lower  part  will  make  it  possible  to  re- 
move the  water  when  the  temperature  has  become  too  low. 

According  to  another  method,  which  has  also  been  frequently  used  and 
apparently  with  equally  satisfactory  results,  the  arrangement  for  blowing 
through  the  ether  is  dispensed  with  ;  a  simple  flask  being  employed  contain- 
ing a  rubber  cork  fitted  with  a  glass  tube  whose  lower  end  is  even  with  the 
lower  end  of  the  rubber  stopper.  To  the  upper  end  of  this  a  glass  tube  is 
attached  which  in  turn  is  attached  to  the  rectal  tube  by  means  of  an  inter- 
vening glass  tube.  Some  surgeons  prefer  to  have  this  attachment  made  by 
means  of  an  intervening  rubber  tube  which  is  fitted  with  a  stop-cock  so  that 


76  GENERAL     SURGICAL     CONSIDERATIONS 

the  flow  of  the  ether  fumes  may  be  interrupted  at  any  time.  The  flask  con- 
taining the  ether  is  then  immersed  in  a  water-bath  at  a  temperature  of  105 
degrees  F.,  which  will  cause  ether  to  evaporate  with  sufficient  rapidity  to 
bring  about  the  anesthesia.  In  case  the  amount  evaporated  is  not  sufficient, 
the  temperature  may  be  increased.  If  the  evaporation  is  too  rapid,  the 
flask  may  be  raised  out  of  the  water-bath  either  partly  or  completely  until  it 
again  becomes  desirable  to  increase  the  amount  of  ether  fumes. 

The  procedure  is  so  simple  that  any  one  who  has  seen  it  applied  once 
can  readily  administer  ether  in  this  way,  but  it  seems  worth  while  to  be  ex- 
plicit in  a  description  because  it  has  not  as  yet  received  practical  application 
to  a  sufficient  extent  to  become  familiar  by  demonstration.  By  substituting 
a  good-sized  thermos  bottle  for  the  container  of  the  warm  water,  with  a 
rubber  cork  that  fits  closely  around  the  upper  end  of  the  bottle  containing  the 
ether,  the  apparatus  can  be  still  further  improved  because  the  water  will 
then  maintain  a  fairly  uniform  temperature  throughout  the  operation  and  the 
slight  decrease  in  temperature  will  be  rather  an  advantage  than  otherwise. 

INCISIONS. 

Rules  Ignored  in  Malignant  Growths. 

In  making  incisions  it  is  important  in  the  first  place  to  bear  in  mind  the 
fact  that  in  operating  for  the  removal  of  malignant  growths  all  rules  con- 
cerning the  direction  and  extent  of  incisions  may  be  disregarded  if  by  re- 
garding them  there  is  the  slightest  danger  of  leaving  any  portion  of  the 
growth  in  the  body  of  the  patient.  In  a  very  large  proportion  of  patients 
that  have  come  under  care  in  an  inoperable  and  hopeless  condition  from 
the  recurrence  of  a  malignant  growth,  some  timid  surgeon  has  made  the 
first  removal  with  a  view  of  obtaining  a  satisfactory  cosmetic  result.  Had 
the  first  excision  been  bold  without  regard  to  the  necessary  deformity,  many 
of  these  patients  would  have  been  permanently  relieved  by  the  first  opera- 
tion. For  this  reason  it  seems  wise  to  insist  at  this  point  on  disregarding  cos- 
metic conditions  absolutely  when  they  interfere  to  the  slightest  degree  with 
thoroughness  in  dealing  with  the  removal  of  malignant  growths. 

In  all  other  cases  there  are  eight  conditions  to  be  borne  in  mind. 

Eight  Rules  of  Guidance. 

1.  The  skin  incision  should  be  made  in  a  manner  to  correspond  with 
the  natural  folds  in  order  to  be  as  little  apparent  as  possible  after  healing 
has  taken  place.     Careful  inspection  of  the  surface  will  always  suggest  posi- 
tion and  direction  of  the  incision,  so  as  to  result  in  the  least  degree  of  de- 
formity for  the  amount  of  disturbance  required  by  the  operation. 

2.  The    underlying   anatomical    structures    must    be    considered.      Of 
these  the  important  nerves  and  the  large  blood  vessels  are  to  be  heeded ;  the 
former  because  if  united  after  having  been  once  severed,  ideal  results  are 
not  usually  obtained  ;  the  latter  because  of  the  danger  of  post-operative  gan- 
grene or  edema  in  the  extremities  and  of  serious  cerebral  disturbances  in 
case  of  section  of  the  large  vessels  in  the  neck. 

3.  At  points  where  muscles,  aponeuroses  or  fascia  are  needed  to  sup- 
port important  parts,  as  in  the  abdominal  wall,  it  is  wise  to  plan  all  incisions 
so  that  the  object  of  the  operation  may  be  accomplished  and  the  structures 
separated  so  as  to  secure  a  fair  amount  of  space  for  performing  the  various 
steps  of  the  operation  and  still  to  have  muscles  and  fascia  separated  or  split 


Fig.   3. 
Anterior   Incisional   Lines. 


GENERAL    SURGICAL     CONSIDERATIONS  79 

rather  than  cut  at  right-angles,  in  order  that  when  the  operation  itself  has 
been  completed  these  separations  or  splittings  may  be  repaired  and  thus  the 
conditions  at  the  conclusion  of  the  operation,  so  far  as  the  tissues  are  con- 
cerned through  which  it  was  necessary  to  secure  entrance,  may  be  as  nearly 
as  possible  the  same  as  they  were  at  the  beginning  of  the  work. 

This  plan  has  the  further  advantage  of  making  it  possible  to  avoid  in- 
injuring  nerves  and  blood  vessels  of  importance  in  the  region  of  the  op- 
eration because  these  usually  lie  in  the  direction  of  and  parallel  to  the 
muscles. 

4.  In  portions  of  the  body  in  which  the  surface  is  exposed,  as  in  the 
neck  and  face,  symmetry  should  be  attained  as  much  as  possible.     In  many 
instances,  as  in  operations  upon  the  forehead,  the  nose,  the  lips,  the  chin  or 
the  neck,  a  one-sided  incision  will  result  in  much  deformity  when  an  in- 
cision extending  over  both  sides,  resulting  in  an  equal  amount  of  exposure  of 
underlying  tissues,  will  cause  but  a  slight  amount  of  deformity. 

5.  It  is  important  to  bear  in  mind  the  occupation  of  the  patient.     Fu- 
ture usefulness  may  be  of  so  much  greater  value  to  the  patient  in  many  in- 
stances than   personal   appearance  that   the   latter  may   be   practically   dis- 
regarded, while  in  other  cases  quite  the  opposite  may  be  the  case. 

6.  It  is  important  to  plan  incisions  so  that  they  will  not  become  pain- 
ful later,  because  of  pressure  or  because  of  the  motion  of  contiguous  joints. 

7.  Wherever  it  is  possible  to  hide  scars  under  the  natural  covering 
of  hair,  as  in  the  region  of  the  eyebrows  or  the  male  beard,  it  is  well  to  take 
advantage  of  these  structures. 

8.  But  while  considering  all  of  these  features,  it  is  important  not  to 
lose  sight  of  the  fact  that  the  incision  must  be  so  planned  as  to  expose  the 
diseased  structures  to  be  treated  during  the  surgical  operation  so  that  this 
treatment  can  be  carried  out  to  the  best  advantage  of  the  patient. 

In  a  general  way  the  incision  should  be  made  in  the  direction  of  the 
muscles,  nerves  and  blood  vessels. 

An  Exceptional  Rule. 

There  is  one  exception  to  this  rule  in  exploring  for  needles  or  other 
thin  objects  that  are  buried  in  the  tissues  and  that  have  been  located  by  the 
use  of  skiagrams.  It  is  practically  impossible  to  find  these  foreign  bodies 
unless  the  incision  is  made  at  right-angles  to  the  object.  Of  course,  if  the 
needle  lies  parallel  to  arteries  and  nerves  then  the  transverse  incision  will 
also  be  at  right-angles  to  these  structures  which  must  be  carefully  found 
and  retracted  to  one  end  of  the  incision  while  the  latter  penetrates  into  the 
depth  beyond. 

\Ye  have  repeatedly  been  able  to  locate  needles  buried  in  the  deep  tissues 
in  a  few  moments  in  cases  in  which  a  search  of  more  than  an  hour  had 
failed  to  locate  the  foreign  body  previously,  because  this  was  attempted 
through  an  incision  parallel  or  nearly  parallel  to  the  foreign  body. 

The  only  structures  that  need  be  considered  in  these  instances  are  the 
nerves  and  the  blood  vessels  in  case  the  latter  are  of  any  considerable  size, 
and  also  the  tendons.  Muscle,  fat,  skin  and  fascia  may  be  severed  and  re- 
united with  catgut  sutures. 

Surface  Incisional  Lines  of  Choice. 

The  choice  of  location  and  direction  for  these  incisions  has  been  care- 
fully worked  out  by  many  surgeons  and  anatomists.  The  scheme  developed 


80  GENERAL    SURGICAL     CONSIDERATIONS 

by  Professor  Sanger,  slightly  modified  to  suit  our  clinical  work,  has  seemed 
most  simple  and  still  sufficiently  comprehensive  to  be  entirely  satisfactory. 

Figs.  3  and  4  represent  the  lines  on  the  anterior  and  Fig.  5  on  the  poste- 
rior surface  of  the  body. 

There  is  a  marked  advantage  in  choosing  these  lines  not  only  from  the 
fact  that  one  can  obtain  convenient  access  to  the  underlying  structures, 
but  also  from  the  fact  that  in  these  locations  one  can  safely  make  the  in- 
cision sufficiently  large  to  obtain  a  free  view  of  the  tissues  to  be  considered 
in  the  operation.  It  is  a  mistake  to  perform  operations  through  incisions 
which  are  too  small  for  fear  of  producing  deformity  from  making  a  larger 
external  wound,  because  if  these  locations  are  chosen  in  a  position  and  di- 
rection which  is  anatomically  correct,  there  is  no  danger  of  obtaining  ugly 
scars  as  the  underlying  muscles  will  not  distort  the  resulting  cicatrix,  and 
these  wounds  heal  without  leaving  any  considerable  deformity.  In  fact  in 
many  instances  it  is  difficult  to  recognize  the  scar  after  a  few  years. 

Separation  of  Deep  Structures. 

It  is,  however,  quite  as  necessary  to  study  the  best  manner  of  separating 
the  deeper  tissues  as  it  is  to  choose  properly  the  position  and  direction  of 
the  external  wound.  Here  again  it  is  important  whenever  possible  to  sep- 
arate the  muscles  instead  of  cutting  them.  Small  arteries  and  veins  may 
be  disregarded.  Large  blood  vessels  should  be  protected,  not  only  against 
direct  injury  but  also  from  crushing  by  the  use  of  retractors,  because  this 
undoubtedly  often  causes  phlebitis  or  thrombosis  after  surgical  operations. 

The  special  details  concerning  incisions  will  be  fully  considered  in  con- 
nection with  each  individual  operation. 

HEMOSTASIS. 
Conserve  the  Blood. 

It  is  important  to  secure  prompt  and  efficient  hemostasis  during  surgical 
operations,  because  there  is  a  direct  relation  between  the  degree  of  shock  and 
the  amount  of  blood  lost  by  the  patient.  Whenever  it  is  possible  to  isolate 
blood  vessels,  to  clamp  them  doubly  by  applying  two  pairs  of  hemostatic 
forceps  to  cut  between  these  and  to  ligate  the  proximal  end,  one  has  ob- 
tained ideal  conditions. 

In  many  operations  this  plan  can  be  carried  out  to  such  an  extent  as  to 
practically  prevent  loss  of  blood  altogether.  Ordinarily,  this  is  of  no  im- 
portance in  itself,  because  most  patients  can  bear  the  loss  of  a  fair  amount  of 
blood  without  harm,  but  hemostasis  also  keeps  the  tissues  clearly  exposed  so 
that  the  anatomical  relations  can  be  kept  perfectly  in  view  constantly  during 
the  operation.  This  not  only  facilitates  the  work,  but  makes  it  possible  to 
suture  the  tissues  with  all  of  the  structures  in  their  normal  relations,  leaving 
the  completed  operation  more  perfect  than  it  would  be  had  the  field  been 
constantly  obscured  by  being  saturated  with  blood. 

Some  surgeons  have  carried  this  idea  to  a  foolish  conclusion.  They 
have  insisted  upon  catching  even  the  smallest  vessels  with  hemostatic  for- 
ceps and  ligating  each  vessel  separately,  thus  consuming  several  times  as 
much  time  as  necessary  in  performing  the  operation.  We  have  seen  a  patient 
kept  under  an  anesthetic  for  a  period  of  four  hours,  at  least  three  of  such 
hours  being  consumed  in  ligating  small  vessels  which  would  have  ceased 
bleeding  within  a  few  moments  without  causing  any  harm  to  the  patient 
whatever. 


Fig.   4. 
Anterior   Abdominal   Incisional  Lines. 


GENERAL     SURGICAL     CONSIDERATIONS  83 

On  the  other  hand  it  is  quite  as  bad  to  be  reckless  about  the  loss  of 
blood  for  such  disregard  is  certain  to  result  in  the  death  of  a  patient  oc- 
casionally. 

It  is  wise  to  use  strong-jawed  hemostatic  forceps  which  will  crush  the 
end  of  the  blood  vessels  of  medium  and  small  size.  These  may  be  left  in 
place  until  the  operation  has  been  completed  when  only  the  large  vessels 
need  to  be  ligated,  the  crushing  having  permanently  closed  the  smaller 
vessels. 

It  is  well  to  bear  in  mind  that  the  surface  of  the  wound  should  not  be 
rubbed  with  sponges  or  gauze  pads  after  these  forceps  have  been  removed, 
because  this  often  opens  up  blood  vessels  which  would  otherwise  remain 
closed  permanently. 

TORSION    OF    BLOOD    VESSELS    FOR    HEMOSTASIS. 

Before  it  was  possible  always  to  obtain  perfectly  sterile,  absorbable  liga- 
tures the  method  of  grasping  blood  vessels  with  hemostatic  forceps  and  twist- 
ing them  in  order  to  permanently  occlude  the  bleeding  point  had  obtained 
many  adherents.  It  is  reasonable  that  this  should  be  so.  Many  surgeons  ap- 
plied this  method  to  vessels  as  large  as  the  brachial  or  the  popliteal  artery. 
Although  this  can  be  done  safely  in  most  cases,  it  would  be  foolish  to  make 
use  of  this  method  in  any  of  the  larger  vessels  at  the  present  time,  because  it 
is  not  as  dependable  as  ligation  and  the  latter  is  quite  as  safe  always  and  has 
no  disadvantages  over  the  former. 

CRUSHING  AND  APPLICATION  OF  HEAT. 

Several  years  ago  many  instruments  were  invented  for  the  purpose 
of  crushing  large  blood  vessels  with  an  enormous  force  applied  to  the 
jaws  of  the  forceps  by  means  of  levers  or  screw  arrangements.  These  in- 
struments are  now  temporarily  obsolete,  but  they  are  certain  to  be  readvised 
from  time  to  time,  although  there  is  no  longer  any  real  need  because  of  the 
fact  that  ligation  with  catgut  ligatures  is  more  convenient  and  in  every  way 
equally  satisfactory  and  somewhat  more  reliable  even  in  the  hands  of  sur- 
geons who  use  the  crushing  forceps  with  the  greatest  care  and  patience. 

Moreover  the  ligature  saves  time  because  the  crushing  forceps  must 
be  left  in  position  at  least  for  a  period  of  one  minute  in  order  to  make  their 
use  fairly  safe.  For  the  average  surgeon  these  powerful  crushing  forceps 
are  not  safe  because  he  will  not  exercise  the  necessary  care  in  applying  them, 
nor  patience  to  leave  in  place  the  necessary  length  of  time.  It  is  quite  a 
different  matter  from  the  use  of  the  strong-jawed  hemostatic  forceps  men- 
tioned above  as  these  can  be  left  attached  to  the  smaller  blood  vessel?  while 
the  operation  proceeds. 

Heated  Clamps. 

Dowd  has  invented  a  clamp  containing  a  coil  of  platinum  wire  for  the 
purpose  of  heating  the  jaws  of  the  instrument  by  passing  a  current  of  elec- 
tricity through  the  coil. 

The  clamp  is  applied  to  a  mass  of  tissue,  like  a  broad  ligament,  then 
its  jaws  are  isolated  from  the  surrounding  tissues  by  a  metal  shield  whose 
construction  makes  it  a  poor  conductor  of  heat,  then  a  current  of  electricity 
is  passed  through  the  forceps  sufficiently  strong  to  heat  the  blades  so  that 


84  GENERAL     SURGICAL     CONSIDERATIONS 

the  stump  will  be  thoroughly  boiled  for  twenty  to  forty  seconds.  The  cur- 
rent is  then  turned  off  and  the  stump  is  cut  beyond  the  clamps  when  the 
latter  are  removed.  In  order  to  prevent  the  jaws  of  these  clamps  from 
adhering  to  the  cauterized  stump  they  are  thoroughly  covered  with  sterile 
olive  oil  before  being  applied. 

The  method  is  perfectly  satisfactory  but  it  seems  indicated  only  in 
cases  in  which  the  portion  beyond  the  pedicle  contains  malignant  tissue, 
as  for  instance  in  case  of  removal  of  uterus,  ovaries,  and  for  the  cure  of 
carcinoma  of  the  uterus.  In  ordinary  operations  the  method  is  in  no  way 
to  be  preferred  to  the  use  of  the  catgut  ligature. 

In  the  removal  of  organs  containing  malignant  growths  the  cauteriza- 
tion of  the  stump  may  prevent  recurrence  in  cases  in  which  there  may  be 
invasion  extending  into  but  not  beyond  the  stump. 

LIGATURE  MATERIAL. 

Catgut  Ligature  the  Best. 

Catgut  prepared  according  to  the  methods  already  described  is  an 
ideal  ligature  material  because  it  has  great  tensile  strength,  it  is  absolutely 
free  from  septic  germs  or  spores,  it  is  thoroughly  rilled  with  minute  crys- 
tals of  iodoform  which  remain  in  the  ligature  until  the  last  portion  has  been 
absorbed  and  thus  prevents  the  ligature  or  the  stump  of  the  vessel  from 
becoming  a  culture  medium  for  micro-organisms  which  may  be  present 
in  the  circulation.  In  any  location  in  which  it  is  possible  for  pressure  necrosis 
to  occur  with  subsequent  infection  due  to  local  conditions  it  is  wise  to  use 
catgut  which  is  so  fine  that  pressure  necrosis  is  not  feared  because  of  the 
fact  that  the  fine  catgut  lacks  tensile  strength  enough  to  crush  the  tissues 
sufficiently  to  cause  their  death. 

Many  surgeons  use  very  fine  silk  ligatures  in  preference  to  catgut,  but 
we  are  convinced  that  their  results  are  better  with  this  ligature  material  only 
because  of  the  fact  that  with  this  fine  silk  they  are  unable  to  cause  pressure 
necrosis  as  they  would  were  they  to  use  catgut  ligatures  of  the  ordinary  size. 

In  ligating  very  large  vessels  it  is  well  to  leave  a  sufficient  portion  of 
the  vessel  projecting  beyond  the  point  at  which  the  ligature  has  been  applied 
so  as  to  prevent  slipping.  It  is  also  well  to  crush  the  wall  of  the  blood 
vessel  at  the  point  at  which  the  ligature  is  to  be  applied  by  the  use  of 
strong  hemostatic  forceps,  as  this  will  crush  all  of  the  soft  tissues  out  of  the 
blood-vessel  wall  and  will  leave  in  place  only  the  connective  tissue  portion. 
The  same  principle  applies  to  the  ligation  of  pedicles  of  considerable  size, 
such  as  the  pedicle  of  an  ovarian  cyst,  or  the  cecal  end  of  the  vermiform 
appendix. 

SEARING  OF  BLEEDING  SURFACES. 

Occasionally  there  is  a  constant  oozing  of  blood  from  the  surface  of  a 
wound  which  does  not  subside  under  pressure  with  hot  moist  gauze  sponges. 
In  these  cases  it.  is  sometimes  well  to  hold  a  red  or  white  hot  cautery  iron 
near  the  surface  without  actually  touching  it.  This  method  is  especially 
useful  in  case  of  oozing  from  bone  surfaces.  Here  the  same  result  may  be 
accomplished  by  an  apparatus  commonly  used  by  artists  in  making  burnt 
woodwork. 

It  is  not  often  necessary  to  resort  to  this  method.     The  application  of 


GENERAL     SURGICAL     CONSIDERATIONS  »/ 

a  gauze  pad  wrung  out  of  very  hot,  or  even  boiling  water  will  usually  ac- 
complish the  same  end  in  a  more  convenient  manner.  In  using  hot  moist 
pads  it  is  important  to  leave  them  in  place  without  change  for  several 
minutes  at  a  time.  If  applied  to  the  oozing  surface  with  pressure  the 
effect  is  more  satisfactory. 

APPLICATION  OF  SUTURES. 

It  is  often  necessary  to  apply  catgut  sutures  to  bleeding  surfaces 
en  masse  because  the  bleeding  may  be  so  diffuse  that  it  is  quite  impossible 
to  catch  each  one  of  the  innumerable  small  vessels  separately.  In  these 
cases  a  suture  is  applied  around  areas  and  tied  in  the  form  of  a  purse-string 
suture  or  two  opposing  surfaces  are  sutured  together,  the  pressure  thus 
caused  upon  both  surfaces  preventing  the  diffuse  hemorrhage.  If  the  wound 
is  near  some  of  the  larger  blood-vessels  it  is,  of  course,  important  not  to 
injure  these  strictures  in  passing  the  sutures  through  the  deep  tissues. 

EXTERNAL  PRESSURE. 

In  many  cases  in  which  large  wound  surfaces  are  produced,  as,  for 
instance,  in  excision  of  the  breast,  it  is  important  to  apply  large  pads  of 
cotton  over  the  surface  when  the  wound  is  dressed  and  to  hold  these  in 
place  by  the  application  of  soft  gauze  rolled  bandages.  The  uniform  pres- 
sure will  result  in  stopping  of  oozing  from  the  surfaces  of  these  large  flaps 
which  may  be  but  very  slight  from  any  one  point,  but  which  would  result 
in  the  loss  of  a  large  amount  of  blood  from  the  entire  surface  were  this 
not  prevented  by  the  careful  application  of  pressure  by  a  properly  ad- 
justed dressing. 

POSITION  OF  EXTREMITIES. 

If  there  is  any  difficulty  in  controlling  hemorrhage  in  the  extremities 
this  can  always  be  accomplished  by  elevating  the  extremity  to  its  fullest 
extent  and  applying  pressure  at  the  point  of  bleeding  until  the  blood-vessel 
can  be  ligated  in  the  wound  or  above  it.  This  is  true,  especially  in  the 
troublesome  hemorrhage  due  to  injury  to  the  plantar  or  the  palmar  arch. 
We  have  encountered  such  cases  in  which  recurrent  hemorrhages  have 
greatly  distressed  both  physician  and  patient  in  whom  permanent  relief  was 
at  once  obtained  upon  elevating  the  extremity,  applying  a  small  compress 
and  keeping  the  part  elevated  for  a  week  or  ten  days.  It  is,  of  course, 
important  not  to  permit  these  patients  to  lower  the  extremity  too  soon 
because  the  pressure  ensuing  is  often  sufficient  to  force  out  the  occluding 
blood  clot  unless  it  has  had  time  to  become  fairly  well  fixed. 

INJURIES  TO  THE  WALLS  OF  BLOOD  VESSELS  DURING 

OPERATIONS. 

Occasionally  a  portion  of  a  blood-vessel  wall  is  intentionally  removed 
during  an  operation,  but  much  more  commonly  this  happens  as  an  accident, 
especially  to  the  large  veins  in  operations  upon  the  neck,  the  axilla  or 
the  groin.  In  these  instances  it  is  well  to  carefully  compress  the  vessel  above 
and  below  the  injured  point.  If  the  opening  is  very  small  it  is  often  pos- 
sible to  grasp  it  with  one  or  two  hemostatic  forceps  with  rounded  ends  and 


88  GENERAL    SURGICAL     CONSIDERATIONS 

to  apply  a  fine,  strong  ligature.  Usually  this  will  close  the  opening  and  the 
result  will  be  precisely  the  same  as  after  ligating  a  lateral  branch  of  a  large 
vein.  Under  such  circumstances  it  is  important  to  apply  the  dressings  very 
snugly  in  order  to  support  the  ligature  in  case  of  increased  intra  venous 
pressure  due  to  vomiting  after  the  operation. 

Repair  of  Bloodvessels. 

Should  the  opening  be  too  large  to  be  closed  by  this  method  it  may  be 
Jtitured  by  means  of  a  very  fine  needle  threaded  with  very  smooth  catgut. 
It  is  best  to  use  the  latter  double  because  the  double  strand  will  more  per- 
fectly fill  the  needle  punctures.  It  is  well  to  wait  a  few  minutes  after  the 
sutures  have  been  applied  before  removing  the  pressure  at  either  side  of 
the  wound  in  order  to  permit  the  needle  punctures  to  become  adherent  to 
the  sutures.  The  distal  compression  should  be  released  first  and  a  little  later 
that  on  the  proximal  side.  The  sutures  are  applied  according  to  a  method 
later  to  be  illustrated  in  connection  with  intestinal  sutures.  It  seems  best 
to  insert  the  sutures  so  that  they  will  not  penetrate  quite  into  the  lumen  of 
the  blood  vessels  for  fear  of  producing  thrombosis. 

At  the  suggestion  of  McAlester,  Guthrie  has  introduced  human  hair  as 
a  substitute  for  catgut  and  silk  in  suturing  blood  vessel  walls,  and  his  plan 
seems  to  be  worth  imitating.  He  uses  a  number  12,  14  or  16  cambric  needle 
which  can  be  obtained  at  drygoods  stores,  choosing  the  small-eyed  variety. 
He  threads  this  with  a  long  human  hair  and  sutures  as  described  above. 
The  hair  is  sterilized  by  boiling  in  paraffin  oil.  This  suture  is  very  fine  and 
still  quite  strong  enough  for  use. 

If  the  vessel  has  been  cut  off  entirely  it  may  be  united  by  these 
sutures,  or  the  two  ends  may  be  threaded  upon  magnesium  rings  and  these 
can  be  forced  against  each  other  by  means  of  fine,  strong  catgut  sutures. 

In  all  of  these  operations  it  is  important  to  exercise  great  care  not  to 
injure  the  intima  in  compressing  the  vessel  above  and  below  the  wound. 
Various  forceps  have  been  invented  for  this  purpose  and  metallic  bands 
have  been  recommended  by  Halstead  and  by  Matas.  Many  surgeons  apply 
temporary  ligatures  while  others  always  have  the  bleeding  controlled  by 
digital  pressure. 

So  long  as  the  vessel  walls,  and  especially  the  intima,  are  not  injured 
it  does  not  matter  what  method  is  chosen. 

In  all  operations  near  large  veins  it  is  of  the  utmost  importance  to 
exercise  great  care  to  prevent  tearing  these  structures  as  the  walls  of  even 
very  large  veins  are  frequently  delicate  and  consequently  very  easily  torn. 
It  is  best  first  to  expose  these  veins  and  then  to  work  away  from  them. 

VESSELS  SEVERED  NEAR  THEIR  ORIGIN. 

Especial  care  must  be  followed  in  ligating  vessels  which  have  been 
severed  near  their  origin.  A  careless  assistant  can  easily  pull  the  remain- 
ing portion  of  a  vein  out  of  the  side  of  the  large  vein  into  which  it  empties, 
thus  leaving  a  lateral  defect  in  the  latter  which  can  often  be  repaired  only 
with  difficulty  by  one  of  the  methods  just  described.  To  make  things  worse 
he  may  make  frantic  efforts  to  stop  the  resulting  hemorrhage  by  wildly 
applying  forceps  to  the  side  of  the  vein  usually  either  increasing  the  original 
defect  or  making  new  ones.  In  these  accidents  it  is  well  always  to  remember 
that  such  an  opening  can  be  closed  at  once  without  the  use  of  any  force 


GENERAL    SURGICAL     CONSIDERATIONS  89 

by  simply  placing  the  end  of  a  finger  over  the  opening.  Then  the  vessel 
can  be  digitally  compressed  above  and  below  the  opening  and  forceps  can 
be  applied  at  leisure  or  the  vent  can  be  closed  with  sutures. 

After  applying  forceps  to  vessels  near  their  origin  it  is  well  always  to 
ligate  at  once  in  order  to  prevent  harm  from  traction  upon  the  handles  of 
the  forceps. 

SUTURING  OF  DEEP  WOUNDS. 

It  is  important  in  all  deep  wounds  to  have  the  surfaces  absolutely  in 
apposition  in  order  to  prevent  the  formation  of  spaces  in  which  quantities  of 
blood  and  serum  may  accumulate. 

In  most  instances  these  accumulations  will  absorb  or  become  organized, 
but  there  is  always  a  possibility  of  infection  through  the  circulation  or  a 
slight  infection  at  the  time  of  operation,  which  would  not  be  sufficient  to 
cause  a  local  disturbance  if  no  good  culture  medium  were  provided,  and 
which  may  cause  some  delay  in  the  ultimate  wound  healing  in  case  spaces 
are  left  between  the  wound  surfaces. 

For  this  reason  it  is  well  to  unite  the  deep  layers  by  means  of  fine 
catgut  sutures  because  union  takes  place  within  a  few  hours  and  then  the 
support  will  no  longer  be  needed. 

Caution  Against  Tight  Sutures. 

It  is  important  to  bear  in  mind,  however,  that  nothing  is  more  favor- 
able for  the  location  of  infection  than  necrosed  areas  due  to  the  application 
of  sutures  drawn  too  tightly.  It  is  consequently  best  to  draw  these  deep 
buried  catgut  sutures  only  just  sufficiently  firm  to  bring  the  surfaces  to- 
gether, but  not  firmly  enough  to  cause  pressure  necrosis. 

By  using  for  this  purpose  fine  catgut  prepared  by  any  one  of  the 
methods  already  described  and  preserved  in  the  iodoform-ether-alco'hol 
mixture  the  results  are  most  satisfactory. 

All  unabsorbable  suture  material,  like  silk,  silkworm  gut,  linen,  silver, 
aluminum  or  bronze  wire  is  to  be  condemned  for  this  purpose.  It  has  no 
advantage  over  the  catgut  and  has  the  very  serious  disadvantage  of  caus- 
ing long  continued  irritation,  necessitating  ultimately  a  removal  of  the 
suture  in  many  cases. 

The  material  least  harmful  among  these  is  very  fine  silk  because  this 
will  in  time  become  absorbed. 

SUTURING  OF  SUPERFICIAL  WOUNDS. 

In  suturing  superficial  wounds  two  kinds  of  sutures  must  be  considered, 
viz.,  those  that  are  used  for  the  purpose  of  coaptating  the  wound  edges,  and 
those  that  are  used  for  the  purpose  of  overcoming  tension  or  for  protecting 
the  wound  against  sudden  strain,  as  in  case  of  sneezing,  coughing  or  vomiting 
Many  wounds  are  located  so  that  there  is  no  tension  at  all  and  in  these  only 
the  coaptation  sutures  are  needed. 

TENSION   SUTURES. 

Where  there  is  severe  tension  it  is  important  to  study  the  degree  thereof 
and  the  direction,  and  to  adjust  the  sutures  to  the  best  advantage  of  the 
existing  conditions.  For  this  purpose  strong  silk  or  wire  sutures  are  most 


9O  GENERAL    SURGICAL     CONSIDERATIONS 

suitable.  The  ends  which  rest  against  the  skin  may  be  attached  to  lead 
plates  or  pledgets  of  gauze.  Since  the  introduction  of  the  Thiersch  method 
of  skin  grafting,  however,  the  tension  suture  is  employed  to  a  much  slighter 
extent  than  formerly,  because  in  most  cases  it  is  better  to  leave  a  surface 
to  be  covered  by  skin-grafts  than  to  put  too  much  tension  on  the  flaps. 

In  all  cases  in  which  there  is  tension  it  is  well  to  leave  the  edges  a  few 
millimeters  apart  at  the  time  the  wound  is  closed,  as  this  will  enable  the 
lymph  to  escape  from  the  edges  of  the  wound  thus  preventing  the  edema 
which  is  certain  to  occur  if  the  wound  edges  are  closely  sutured,  and  this 
edema  favors  necrosis  of  the  flap.  This  is  especially  to  be  borne  in  mind 
in  all  cases  in  which  there  is  arteriosclerosis,  and  still  more  in  cases  that 
are  suffering  from  diabetes. 

Wherever  it  is  possible  to  plan  an  operation  so  that  there  will  be  no 
tension  this  should  be  done,  and  in  no  case  should  sutures  be  tied  tightly 
enough  to  cause  pressure  necrosis. 

SUPERFICIAL   SUTURES. 

In  suturing  superficial  w-ounds  certain  principles  must  be  observed  with- 
out regard  to  suture  material. 

1.  Sutures  should  be  drawn  just  tightly  enough  to  bring  the  wound 
edges  together,  but  not  sufficiently  tight  to  cause  pressure  necrosis. 

2.  Allowance  should  be  made  for  the  edema  which  always  occurs  a 
day  or  two  after  the  operation. 

3.  The  bite  of  the  needle  should  be  equal  on  both  sides  of  the  in- 
cision, both  as  to  depth  and  length  of  stitch. 

4.  The   tension    should   be   disposed   of   by   one   set   of   sutures,    the 
coaptation  by  another  which  may,  however,  also  be  accomplished  by  making 
one  deep  and  one  superficial  stitch  alternately. 

METAL    CLIPS. 

Many  different  metal  clips  have  been  invented  and  some  of  these  are 
quite  as  satisfactory  as  the  various  sutures  which  have  been  described ;  they 
are,  however,  much  more  expensive  and  this  element  must  be  considered  espe- 
cially in  hospital  work.  Results  are  no  better  than  with  sutures,  conse- 
quently their  employment  must  remain  entirely  a  matter  of  personal  choice. 

NON-ABSORBABLE   SUTURE   MATERIAL. 

The  most  useful  suture  materials  of  this  class  consist  of  silk,  linen, 
horsehair,  silkworm  gut,  silver,  bronze,  or  aluminium  wire.  The  first,  sec- 
ond and  third  may  be  impregnated  with  celluloidin  or  with  paraffin  to  pre- 
vent the  entrance  of  pus.  The  others  are  all  impermeable.  All  of  these 
materials  may  be  used  both  as  superficial,  removable  sutures  or  they  may 
be  buried,  but  in  the  latter  case  they  are  certain  to  cause  much  annoyance 
both  to  the  surgeon  and  to  the  patient,  because  in  the  event  of  infection  they 
will  later  have  to  be  removed  and  usually  the  patient  will  have  this  service 
performed  not  by  the  surgeon  who  applied  the  sutures  originally,  but  by 
some  one  who  never  uses  unabsorbable  buried  sutures,  or  by  another  who 
has  for  some  time  abandoned  this  practice. 

If  applied  as  buried  sutures  it  is  important  not  to  include  muscles  in 


GENERAL    SURGICAL     CONSIDERATIONS  91 

the  bite  of  the  suture,  as  the  contraction  of  the  muscles  is  very  likely  to 
cause  these  unabsorbable  sutures  to  act  as  irritating-  foreign  bodies. 

Each  of  these  materials  has  its  advocates  because  of  some  especial 
virtue,  such  as  pliability,  ease  of  application,  non-absorption  of  wound 
secretion,  slight  antiseptic  qualities  as  with  silver  wire,  slight  elasticity,  as 
in  case  of  horsehair,  cheapness,  as  in  case  of  silk,  linen  and  horsehair. 

As  a  matter  of  fact  if  applied  without  tension  all  of  these  materials 
are  very  satisfactory.  The  various  conditions  under  which  one  or  the  other 
is  preferable  will  be  mentioned  in  connection  with  the  particular  operations. 

ABSORBABLE  SUTURE  MATERIAL. 

Catgut  is  the  only  absorbable  suture  material  that  needs  to  be  con- 
sidered because  if  properly  prepared  it  fills  every  requirement.  It  is  more 
expensive  than  silk,  linen  and  horsehair,  and  should  consequently  not  be  used 
where  these  will  serve  the  same  purpose.  It  is  quite  as  satisfactory  in  every 
particular  as  kangaroo  tendon,  and  vastly  superior  in  many  respects  and 
should  therefore  displace  the  latter  entirely. 

If  the  methods  of  preparation  and  preservation  described  heretofore  are 
carefully  carried  out  this  material  is  absolutely  reliable  both  as  regards 
tensile  strength,  time  required  for  absorption  and  absolute  asepsis.  These 
methods  are  moreover  so  simple  that  any  honest  person  can  have  perfect 
results  and  there  are  many  manufacturers  who  supply  the  catgut  prepared 
so  that  it  can  be  used  without  any  fear  of  infection  from  this  source. 

AFTER  TREATMENT  OF  ASEPTIC  WOUNDS. 
Don't  Meddle. 

It  is  most  important  to  bear  in  mind  that  the  less  one  meddles  with 
aseptic  wounds  after  they  have  been  carefully  sutured  and  dressed  the  more 
certain  one  can  be  of  obtaining  primary  union.  If  the  sutures  have  not 
been  drawn  too  tightly  there  will  be  no  pressure  necrosis  and  consequently 
the  staphylococci  which  are  always  present  in  the  skin  will  not  find  any 
culture  medium.  It  is  well  to  dress  the  wound  on  the  fifth  to  the  seventh 
day,  being  careful  not  to  pull  the  united  wound  edges  apart  by  rough 
handling.  Then  it  is  well  to  paint  the  line  of  suture  with  compound  tincture 
of  iodine  and  remove  the  superficial  sutures,  then  once  more  paint  the  sur- 
face with  the  same  solution,  and  then  reapply  an  aseptic  dressing  leaving 
the  deep  sutures  to  be  removed  later  as  indicated  in  connection  with  the 
various  operations. 

Support  by  Strapping. 

The  tincture  of  iodine  seems  to  obliterate  the  little  suture  marks. 

When  the  deep  sutures  have  been  removed  it  is  well  to  apply  a  rubber 
adhesive  plaster  to  each  side  of  the  wound  and  about  two  inches  away  from 
its  edge.  These  straps  should  contain  a  number  of  tapes,  about  one  for 
every  four  cm.  of  length  of  wound.  These  straps  are  applied  and  left  untied 
for  a  day  or  two  in  order  to  secure  perfect  attachment  to  the  skin  then  the 
tapes,  which  should  be  so  arranged  as  to  be  opposite  each  other,  should  be 
tied  sufficiently  firm  to  remove  all  tension  from  the  wound  itself.  In  this  way 
it  is  possible  to  obliterate  the  scar  almost  completely.  Unless  this  precau- 
tion is  taken  the  wound  frequently  becomes  drawn  out  into  an  ugly,  broad, 
white,  disfiguring  mark. 


92  GENERAL    SURGICAL     CONSIDERATIONS 

Unless  the  sutures  are  tied  loosely  each  one  leaves  a  transverse  mark 
across  the  wound,  which  is  also  likely  to  be  very  unsightly. 

Occlusive  and  Antiseptic  Applications. 

Various  substances  have  been  recommended  for  application  to  the 
wound  for  the  purpose  of  preserving  asepsis  and  preventing  the  formation 
of  ugly  scars,  of  these  flexible  collodion  and  concentrated  tincture  of 
benzoin  are  the  best.  Of  the  various  powders  those  that  are  non-irritating 
and  odorless  and  contain  some  form  of  iodine  are  the  best.  Most  of  these 
are  made  under  some  patent  and  as  wounds  heal  quite  as  perfectly  without 
their  use  it  does  not  seem  proper  or  necessary  to  mention  them  specifically. 

Avoid  Any  Unnecessary  Manipulations. 

It  is  very  important  never  to  crush  or  manipulate  wounds  at  the  time 
of  dressing.  Inexperienced  assistants  seem  to  have  an  insane  desire  to  feel 
of  wounds  and  there  can  be  no  doubt  that  the  gratification  of  this  desire 
results  in  the  infection  of  many  wounds  which  would  otherwise  heal  by  first 
intention. 

Removal  of  Sutures. 

In  removing  the  superficial  sutures  great  care  should  be  exercised  not 
to  separate  the  delicately  united  wound  edges.  It  is  much  better  not  to 
touch  these  sutures  for  two  weeks  after  they  have  been  applied  than  to 
disturb  the  edges  in  the  least  while  removing  them  early  in  order  to  prevent 
the  stitch  marks.  A  careful  assistant,  with  reasonable  patience  can,  how- 
ever, remove  these  superficial  sutures  with  proper  forceps  and /scissors  with- 
out fear  of  causing  this  disturbance. 

AFTER  TREATMENT  OF  PRIMARILY  SEPTIC  WOUNDS. 

Every  surgeon  encounters  many  wounds  that  are  primarily  septic  in 
cases  which  come  to  him  because  of  the  presence  of  a  septic  condition. 
In  these  the  following  results  must  be  obtained : 

1.  The  accumulation  of  septic  material  must  be  evacuated. 

2.  Provision  must  be  made  against  reaccumulation  of  septic  material. 

3.  Absorption  of  septic  material  must  be  prevented. 

The  first  of  these  conditions  is  accomplished  by  free  incision  which 
must  of  course  be  varied  according  to  the  character  and  the  location  of  the 
infection.  The  second  object  is  accomplished  by  the  use  of  drainage  tubes 
or  tampons  which  must  again  vary  according  to  conditions,  and  this  will 
in  turn  accomplish  the  third  object.  These  steps  will  cause  the  lymph 
stream  to  pass  away  from  the  infected  tissues  carrying  with  it  the  septic 
material  which  is  deposited  upon  the  dressings.  Thus  the  infection  of 
tissues  hitherto  free  will  be  prevented  in  a  physiological  way.  In  the  mean- 
time if  the  infection  is  in  an  extremely  venous  congestion  should  be  pre- 
vented by  elevating  the  extremity  and  progress  of  the  infection  through  the 
lymph  channels  should  be  prevented  by  placing  the  part  of  the  body  affected 
perfectly  at  rest. 

The  elimination  through  the  lymph  stream  can  be  stimulated  by  the 
application  of  warm  moist  dressings.  It  is  possible  that  by  adding  mild, 
non-poisonous  antiseptics  like  boric  acid  and  alcohol  to  these  dressings  that 
they  will  further  aid  the  processes  of  disinfection.  Kahlenberg  has  demon- 
strated that  boric  acid  is  rapidly  absorbed  when  applied  in  aqueous  solution 


GENERAL    SURGICAL     CONSIDERATIONS  93 

externally,  whether  in  sufficient  quantity  to  have  a  beneficial  effect  has  not 
been  proven  although  clinical  observation  seems  to  bear  out  this  idea. 

Later  on  the  healing  can  be  accelerated  by  stimulating  the  wound  sur- 
faces by  the  application  of  compound  tincture  of  iodine  or  2  to  10  per 
cent,  solution  of  nitrate  of  silver,  or  any  one  of  a  number  of  other  sub- 
stances. In  case  of  septic  cavities  the  application  later  on  of  Beck's  bismuth 
paste, — one  part  of  arsenic,  free  bismuth  subnitrate  in  two  parts  of  vaseline, 
— is  followed  by  excellent  results. 

This  should  be  applied  at  first  each  day  and  later  on  less  frequently, 
and  should  be  kept  in  contact  with  the  deep  surfaces  by  transfixing  the 
external  wound. 

AFTER    TREATMENT    OF    CLEAN    WOUNDS    BECOMING   INFECTED. 

Whenever  there  is  any  evidence  of  infection  occuring  in  a  wound  which 
was  primarily  clean  it  is  well  at  once  to  remove  several  sutures,  especially 
at  points  showing  redness,  and  to  apply  a  large,  hot,  moist  antiseptic  dress- 
ing consisting  preferably  of  one  part  of  alcohol  and  two  parts  of  a  suturated 
aqueous  solution  of  boric  acid  to  the  surface,  and  to  cover  this  dressing  with 
some  impermeable  substance  like  gutta  percha  tissue  or  oiled  muslin.  These 
wounds  should  not  be  maniuplated.  If  the  infection  does  not  subside  at  once 
then  the  wound  should  be  opened  a  little  further  or  in  severe  cases  it  may 
become  necessary  to  open  the  wound  throughout. 

From  this  point  on  the  treatment  should  be  the  same  as  in  the  cases 
just  described.  Usually  the  infection,  however,  subsides  promptly  upon 
taking  the  first  step  mentioned  above.  In  each  case  the  cause  should  be 
determined.  It  is  usually  a  slight  error  in  technic  which  can  readily  be 
corrected  to  the  benefit  of  patients  operated  on  subsequently. 

Prevention. 

Of  course  benefit  must  come  chiefly  from  prevention,  and  this  must 
depend  largely  upon  the  organization  of  a  reasonable  system,  and  in  this 
system  every  person  must  fully  appreciate  the  fact  that  he  carries  an  im- 
portant portion  of  the  responsibility.  In  this  the  permanency  of  service  is  a 
most  important  matter  so  far  as  the  assistants  are  concerned,  and  per- 
manency of  methods  is  equally  important,  chiefly  because  of  the  fact  that 
this  secures  conditions  in  which  possible  flaws  or  weak  points  are  known 
and  can  be  guarded  against,  and  because  any  neglect  in  carrying  out  the 
methods  can  be  more  readily  recognized  than  when  changeable  plans  are 
employed. 

SURGICAL    INSTRUMENTS. 

It  is  well  to  become  accustomed  to  the  use  of  as  few  instruments,  and 
of  as  simple  construction  as  possible,  as  in  this  manner  the  surgeon  becomes 
so  familiar  \vith  each  instrument  that  he  can  use  it  with  the  same  facility 
that  the  skilled  artisan  shows  in  the  use  of  his  tools.  This  enables  the  sur- 
geon to  reduce  the  time  required  by  the  operation  to  a  minimum,  and  at  the 
same  time  each  operation  when  completed  is  technically  as  nearly  perfect  as 
it  can  be. 


PART   II. 


SURGERY  OF  THE  HEAD. 

INJURIES  TO  THE  SCALP. 

Infection  Favored  by  Location. 

In  considering  scalp  injuries  it  is  important  to  bear  in  mind  the  fact 
that  the  conditions  in  this  location  are  especially  favorable  for  the  occurrence 
of  infection,  and  that  it  is  especially  in  persons  who  are  most  liable  to 
scalp  injuries  that  the  conditions  are  most  favorable  for  infection,  primarily 
because  working  people,  and  notably  those  working-  among  horses  and 
cattle  and  on  the  streets,  are  certain  to  have  unclean  scalps,  and,  secondly, 
the  dirt  with  which  they  come  in  contact  is  most  likely  to  contain  pathogenic 
micro-organisms,  of  which  the  pyogenous  staphylococci  and  streptococci 
are  most  numerous.  In  persons  working  among  horses  the  tetanus  bacillus 
is  also  frequently  present.  It  is  consequently  proper  at  this  point  to  refer 
to  the  matter  of  disinfection  of  the  scalp  as  this  is  of  the  very  greatest 
importance,  even  though  there  may  be  no  fracture  of  the  skull.  The  scalp 
is  likely  to  contain  the  streptococci  of  erysipelas,  and  this  infection  may 
extend  through  the  skull  by  way  of  the  veins — giving  rise  to  a  septic  men- 
ingitis. In  my  experience  this  has  happened  in  a  number  of  cases  in  which 
the  injury  was  due  to  a  blow  with  a  blunt  object,  such  as  a  brick  or  a  piece 
of  iron  or  anything  hard  or  heavy.  The  disinfection  in  these  cases  should 
be  just  as  thorough  as  though  an  operation  were  contemplated;  and  it  is 
well  afterward  to  apply  a  moist,  antiseptic  dressing  of  some  kind  and  cover 
with  some  impermeable  material,  such  as  gutta  percha,  in  order  to  com- 
plete the  disinfection.  The  sooner  this  is  accomplished  after  the  time  of 
the  injury  the  better.  It  is  unfortunate  if  it  be  postponed  until  the  tissues 
have  become  edematous  as  a  result  of  infection. 

In  these  cases  the  amount  of  hemorrhage  has  usually  been  so  consider- 
able that  the  hair  is  thoroughly  saturated  with  blood. 

Antiseptic  Measures. 

If  the  wound  is  fairly  clean-cut  and  not  very  large  it  usually  suffices 
to  wash  the  scalp  thoroughly  with  soap  and  hot  water,  then  to  shave  away 
the  hair  for  one  or  two  cm.  beyond  the  edge  of  the  wound  in  all  directions 
and  then  to  wash  the  surface  with  strong  alcohol  and  with  one  to  one- 
thousand  corrosive  sublimate  in  hot  water ;  then  again  with  strong  alcohol 
and  finally  to  mop  the  wound  and  the  surrounding  scalp  with  strong  com- 
pound tincture  of  iodine. 

If  the  wound  is  very  small  and  if  one  is  certain  that  there  is  no  frac- 
ture of  the  skull  it  is  often  not  necessary  to  shave  away  any  of  the  hair 
if  the  scalp  is  thoroughly  treated  according  to  the  method  just  described. 


96  SURGERY   OF    THE   HEAD 

On  the  other  hand,  if  the  scalp  has  been  badly  crushed  and  if  the  wound 
is  extensive,  and  especially  if  there  is  a  fracture  of  the  skull,  it  is  often 
best  to  shave  the  entire  head  so  that  in  the  manipulations  which  will  be 
required  in  treating  the  conditions  found,  there  is  no  danger  of  carrying1 
infectious  material  from  the  remaining  hair  to  the  wound  or  to  the 
meninges. 

Application  of  Tincture  of  Iodine. 

Recently  disinfection  without  preliminary  scrubbing  by  saturating  the 
dry  surface  with  strong  tincture  of  iodine,  or  10  per  cent  of  iodine  dissolved 
in  benzine  or  in  chloroform,  has  been  advocated.  In  cases  in  which  the 
wound  has  been  disinfected  immediately  and  simply  dressed  with  dry 
aseptic  dressing  and  sent  to  the  hospital  for  treatment,  arriving  dry,  this 
method  may  be  acceptable.  In  the  usual  scalp  wounds,  however,  it  seems 
unwise  to  depend  upon  this  simple  course. 

When  the  Wound  is  Clean-cut. 

When  the  wound  is  clean-cut  and  there  is  no  undermining  of  the 
scalp  it  is  well  to  apply  just  a  sufficient  number  of  sutures  to  secure  coapta- 
tion,  but  no  more,  in  order  to  permit  the  serum  to  escape  between  the 
sutures.  This  will  insure  rapid  healing,  even  if  there  is  a  slight  amount 
of  infection,  because  the  blood  supply '  is  very  abundant  and  the  serum 
escaping  between  the  sutures  will  eliminate  safely  a  considerable  amount 
of  septic  material. 

When  the  Tissues  Are  Undermined. 

If  the  edges  of  the  wound  are  undermined  the  wound  should  be 
enlarged  to  a  point  just  beyond  the  undermined  portion  and  then  sutured, 
with  a  little  space  left  open  for  drainage  at  each  end.  If  the  undermining 
is  extensive  it  is  well  to  make  one  or  more  small  incisions  at  the  base  of 
each  flap  caused  by  the  undermining,  and  in  bad  cases  to  draw  small  drain- 
age tubes  or  strands  of  silkworm  gut,  or  folded  gutta  percha  tissue,  through 
these  openings  to  facilitate  drainage. 

It  is  desirable  to  cover  the  wound  with  a  hot  moist  dressing  com- 
posed of  aseptic  gauze  wrung  out  of  a  mixture  of  two  parts  of  a  4  per 
cent  solution  of  boric  acid  in  hot  water  and  one  part  of  strong  alcohol. 
Some  impermeable  substance,  like  gutta  percha  tissue  or  oiled  silk,  is  placed 
over  this  and  cotton  and  a  bandage  over  all. 

INFECTED   SCALP  WOUNDS. 

It  frequently  happens  that  scalp  wounds  are  sutured  hurriedly,  without 
sufficient  cleansing,  directly  or  some  time  after  their  occurrence,  or  that 
they  are  not  cared  for  at  all  for  some  hours  or  even  days  after  their  inflic- 
tion, and  that  when  they  finally  come  under  the  attention  of  a  surgeon 
infection  has  taken  place,  which  may  be  of  any  degree  of  severity  from  the 
slightest  infection  to  a  degree  so  severe  that  the  patient's  temperature  may 
exceed  105°  F.,  or  he  may  even  be  unconscious. 

Thorough  Opening  of  Infected  Wounds. 

In  these  severe  cases  it  is  wise  invariably  to  remove  all  of  the  sutures 
and  to  open  up  the  wound  widely.  Upon  doing  this  we  have  found  all  kinds 
of  objects,  like  hair,  straw,  sticks  of  wood,  stones,  sand  and  many  other 


SURGERY  OF  THE  HEAD  97 

things  sewed  up  in  such  scalp  wounds.  In  these  cases  the  wound  should 
be  enlarged  to  the  extent  of  the  undermining  and  a  number  of  small 
incisions  should  be  made  at  the  base  of  each  flap.  The  space  underneath 
the  flaps  should  then  be  loosely  packed  with  moist  gauze  and  the  entire1 
scalp  covered  with  the  hot  moist  antiseptic  dressing  previously  described. 
This  should  be  renewed  daily  until  the  sepsis  has  entirely  subsided  and 
then  the  edges  of  the  wound  should  be  sutured  loosely  and  dressed  as  a 
clean  scalp  wound. 

Immunizing  Tetanus  Antitoxin. 

If  the  wound  has  been  soiled  with  street  dust  or  with  garden  earth,  or 
if  the  patient  has  recently  come  in  contact  with  horses,  from  1,000  to  3,000 
units  of  tetanus  antitoxine  should  be  injected  subcutaneously.  If  this  soil- 
ing, just  named,  has  been  severe  it  is  well  to  repeat  the  injection  after 
twelve  or  twenty-four  hours.  If  the  scalp  wound  is  in  the  vicinity  of  the 
external  auditory  meatus  it  is  advisable  to  place  a  few  drops  of  strong 
compound  tincture  of  iodine  in  the  meatus,  so  that  all  parts  of  its  surface 
will  be  covered  with  this  remedy,  and  after  half  an  hour  the  ear  should  be 
filled  with  a  10  per  cent  solution  of  carbolic  acid  in  glycerine.  This  appli- 
cation of  carbolic  acid  and  glycerine  should  be  repeated  once  or  twice  daily 
until  it  is  certain  that  the  wound  will  not  have  an  erysipelatous  complica- 
tion. In  case  this  should,  however,  occur  the  treatment  should  be  continued 
in  order  to  prevent  an  infection  of  the  meninges  through  this  channel. 

TUMORS  OF  THE  SCALP. 

Sebaceous  Cysts. 

The  most  common  tumors  in  this  region  are  sebaceous  cysts,  which 
may  vary  in  size  from  that  of  a  bird-shot  to  that  of  a  fist,  although  they 
usually  become  infected  before  attaining  extreme  size  and  they  then  necrose 
at  some  point  and  their  contents  is  spontaneously  evacuated  through  the 
opening  thus  formed.  They  may  also  be  injured  by  the  use  of  comb  or 
hatpin  and  a  superficial  ulcer  thus  may  occur  which  usually  induces  the 
patient  to  give  the  condition  surgical  attention. 

There  is  no  pain  in  these  cysts  unless  they  are  inflamed,  but  they  are 
the  cause  of  marked  deformity  and  much  inconvenience  in  dressing  the  hair. 

Modern  Treatment  and  Recurrence. 

In  preantiseptic  days  there  was  much  prejudice  against  surgical  treat- 
ment of  this  condition  because  of  frequent  recurrence,  and  the  operation 
was  often  followed  by  an  erysipelas  which  sometimes  resulted  in  the  death 
of  the  patient.  The  first  objection  has  now  been  eliminated  owing  to  the 
certainty  with  which  it  is  possible  to  remove  the  entire  cyst  wall.  It  is, 
however,  to  be  borne  in  mind  that  every  sebaceous  gland  in  the  scalp  is 
capable  of  forming  a  sebaceous  cyst,  and  consequently  the  removal  of  the 
existing  cysts  will  not  prevent  the  formation  of  further  similar  cysts  from 
any  of  the  remaining  sebaceous  glands  in  the  scalp. 

It  would  consequently  not  be  wise  to  give  the  patient  the  impression 
that  by  having  the  existing  cysts  removed  he  would  in  the  future  be  free 
from  this  condition.  Indeed,  it  has  been  found  that  persons  who  have  once 
had  sebaceous  cysts  of  the  scalp  are  especially  liable  to  the  formation  of 
similar  growths  from  other  sebaceous  cysts  in  the  same  region.  It  is  also 


98  SURGERY   OF   THE  HEAD 

well  to  examine  carefully  all  of  the  portions  of  the  scalp  before  the  opera- 
tion, in  order  to  discover  any  small  cysts  which  may  be  just  appearing. 

Early  in  the  antiseptic  era  it  was  customary  to  shave  the  entire  scalp 
before  removing  even  a  single  sebaceous  cyst,  in  order  to  secure  an  abso- 
lutely perfect  asepsis. 

This  is  no  longer  necessary,  as  it  has  been  found  that  if  the  plan  of 
disinfecting  the  scalp  that  has  just  been  described  is  carried  out  the  wound 
resulting  from  the  operation  will  regularly  heal  by  first  intention,  even  if 
no  part  of  the  hair  has  been  shaved. 

It  is  claimed  that  by  simply  saturating  the  dry  scalp  thoroughly  and 
repeatedly  with  compound  tincture  of  iodine  for  a  period  of  ten  minutes 
and  permitting  this  to  become  dry  that  the  operation  can  be  performed 
safely  without  any  further  attempts  at  disinfection.  In  place  of  the  com- 
pound tincture  of  iodine  a  10  per  cent  solution  of  iodine  in  benzine  or  in 
chloroform  may  be  employed. 

Our  own  results  have  been  so  absolutely  satisfactory  by  following  the 
method  described  above  that  we  have  not  undertaken  to  test  these  iodine 
methods,  which  are,  however,  vouched  for  by  perfectly  reliable  authorities 
with  much  experience  and  good  surgical  judgment. 

Technique  of  Removal. 

The  cysts  having  been  definitely  located,  counted  and  marked  by  the 
application  of  a  spot  of  tincture  of  iodine  directly  over  the  mass,  the  hair 
is  separated  and  a  sharp-pointed  scalpel  is  thrust  directly  through  the  scalp 
and  the  underlying  cyst,  splitting  the  latter  and  its  contents  in  halves.  The 
cyst  wall  is  much  more  adherent  to  the  surrounding  tissues  at  its  most 
superficial  point  than  elsewhere  on  its  surface,  hence  it  is  wise  to  grasp  the 
deepest  portion  of  the  cyst  wall  with  hemostatic  or  dissecting  forceps  and 
to  enucleate  it  from  within  outwards.  In  a  fraction  of  a  minute  a  cyst 
can  be  removed  in  this  manner  and  unless  too  large  a  number  of  cysts  are 
present  the  work  can  be  done  without  general  or  local  anesthetics.  If  there 
are  several  of  these  cysts  present  it  is  well  to  administer  morphin  hypo- 
dermically  half  an  hour  before  the  operation  in  order  to  blunt  the  sensi- 
bility of  the  patient  to  some  extent. 

The  wound  must  be  carefully  examined  to  determine  that  no  part  of 
the  cyst  wall  has  been  left  behind.  If  these  steps  are  carefully  carried  out 
it  is  but  seldom  that  any  portion  of  the  cyst  wall  remains. 

This  method  is  much  more  satisfactory  than  the  removal  of  these  cysts 
by  dissection,  not  only  because  of  its  ease  and  rapidity,  but  also  because  of 
the  fact  that  recurrence  follows  much  more  rarely,  if  at  all,  on  account  of 
leaving  portions  of  the  cyst  wall.  From  one  to  three  fine  cutgut  sutures 
should  be  introduced  and  a  gauze  and  cotton  dressing  applied,  which  may 
be  removed  in  one  week.  Other  benign  tumors,  like  lipo-fibroma,  angioma, 
lyinphoma,  occur  underneath  the  scalp  and  these  are  treated  as  elsewhere 
in  the  body. 

Sarcoma  and  Carcinoma. 

Sarcoma  and  carcinoma  of  the  scalp  should  be  treated  by  wide  excision, 
together  with  periosteum  covering  the  skull.  It  is  well  tn  apply  the  actual 
cautery  to  the  surface  of  the  bone  after  the  tumor  has  been  removed  and 
to  secure  deep  cauterization  of  the  bone  in  this  way.  The  cauterized  bone 
will  be  exfoliated  after  several  weeks  and  the  surface  may  be  covered  with 
Thiersch  skin-grafts  unless  the  tumor  is  located  at  a  point  at  which  this1 


SURGERY  OF   THE  HEAD  99 

would  leave  an  especially  unsightly  deformity,  in  which  case  the  scalp 
covered  with  hair  from  some  other  part  of  the  head  may  be  mobilized  in 
the  form  of  a  flap  of  proper  size  and  this  may  be  slid  over  the  defect  and 
sutured  in  place.  The  new  defect  which  has  been  formed  in  this  manner 
should  be  covered  with  Thiersch  grafts  at  once. 

TUBERCULOSIS  OF  THE  SCALP. 

Tuberculosis  of  the  scalp  is  not  a  common  condition.  When  it  does 
occ'ir  it  should  be  treated  by  the  method  just  described  for  the  relief  of 
malignant  growths  unless  the  area  involved  is  small,  in  which  event  it  is 
well  to  destroy  the  infected  tissue  with  the  actual  cautery  down  to  the  skull, 
including  the  surrounding  tissue  for  a  distance  of  one  c.m.  When  the 
eschar  has  separated,  the  surface  should  be  covered  by  a  Thiersch  skin- 
graft. 

NON-TRAUMATIC  INFECTION  OF  THE  SCALP. 

Non-traumatic  infections  of  the  scalp  should  be  treated  like  the  same 
condition  involving  other  parts  of  the  skin,  but  it  is  important  to  remember 
the  fact  that  apparently  non-traumatic  infections  of  this  region  are  usually 
due  to  traumatism  caused  by  the  presence  of  parasites  or  to  scratching  to 
relieve  itching  of  a  scalp  which  is  not  kept  clean.  Wre  have  seen  more  of  this 
since  the  introduction  of  the  fantastic  fashion  of  hair-dressing  in  vogue  at 
the  present  time. 

In  the  former  case  it  is  important  as  an  initial  step  to  destroy  the 
parasites  and  to  place  the  hair  and  the  scalp  in  an  aseptic  condition,  and 
to  prevent  reinfection  from  the  material  used  in  dressing  the  hair.  In  the 
second  place,  it  must  be  borne  in  mind  that  it  is  much  more  difficult  to  use 
moist  antiseptic  dressings  effectively  on  hair-covered  skin  surfaces  unless 
especial  attention  is  paid  to  this  condition,  as  the  hair  is  likely  to  become 
matted  together  and  to  prevent  the  antiseptic  fluid  from  touching  the  under- 
lying skin. 

It  is  but  rarely  necessary  to  remove  the  hair,  however,  if  the  dressing 
of  these  cases  is  carried  out  carefully  and  intelligently,  but  if  left  to  assist- 
ants, without  especial  instruction,  these  cases  usually  progress  badly. 

In  all  other  respects  the  treatment  must  be  the  same  as  for  infections 
of  other  portions  of  the  skin. 

INJURIES    OF   THE   SKULL. 
Diagnosis. 

Although  injuries  to  the  skull  are  more  commonly  associated  with 
wounds  of  the  scalp,  it  is  important  always  to  remember  that  the  absence  of 
an  external  wound  does  not  necessarily  mean  an  absence  of  skull  injury, 
and  it  is  just  in  these  cases  that  a  diagnosis  is  often  difficult  and  sometimes 
impossible.  If  a  definite  depression  of  the  bone  can  be  felt  the  diagnosis 
is  easily  made,  but  this  is  sometimes  simulated  by  an  abrupt  depression  due 
to  the  fact  that  the  subcutaneous  tissue  has  been  crushed  by  a  heavy,  sharp- 
edged  object,  which  has  left  a  portion  of  the  subcutaneous  tissue  entirely 
untouched,  while  the  tissue  just  beyond  has  been  so  thoroughly  crushed 
that  it  feels  like  a  depression,  while  the  sharp  edge  of  the  tissue  beyond! 
feels  like  the  edge  of  the  fractured  bone. 


TOO  SURGERY  OF   THE  HEAD 

In  case  of  doubt  it  is  always  best  to  expose  the  area  in  question  by 
making  a  scalp  flap  sufficiently  large  to  allow  one  to  examine  the  conditions. 
This  will  not  often  be  necessary,  because  with  some  experience  one  is  able 
to  recognize  this  condition,  but  the  method  is  undoubtedly  justifiable  in 
case  of  doubt. 

Fracture  of  the  skull  may  cause  no  immediate  symptoms  aside  from 
the  shock  and  temporary  unconsciousness  due  to  the  accompanying  con- 
cussion of  the  brain.  The  injury  may  consist  of  a  single  fissure  with  or 
without  laceration  of  periosteum  or  dura,  or  both,  or  it  may  be  accom- 
panied by  more  or  less  severe  depression.  The  bone  may  be  driven  into 
the  substance  of  the  brain,  or  the  latter  may  be  quite  uninjured  because 
of  its  elasticity  and  the  character  of  the  blow. 

Of  the  injuries  to  the  blood  vessels  a  laceration  of  the  meningeal  artery 
at  some  point  is  most  common  and  this  is  by  far  the  most  treacherous  con- 
dition because  of  the  ease  with  which  it  may  be  overlooked  unless  the  possi- 
bility of  its  occurrence  is  kept  very  prominently  in  one's  mind,  even  in  con- 
nection with  head  injuries  which  at  first  seem  so  slight  as  to  be  scarcely 
worthy  of  serious  attention. 

LIGATION  OF  THE  MIDDLE  MENINGEAL  ARTERY. 

These  cases  very  commonly  have  the  following  history:  A  patient 
receives  a  slight  injury  from  which  he  recovers  in  a  very  short  time,  usually 
within  a  few  minutes.  He  is  able  to  go  to  his  home,  but  later  on  becomes 
unconscious,  his  pulse  becomes  slow,  and  unless  relief  is  secured  within  a 
very  short  time  the  patient  succumbs  to  the  effects  of  intra-cranial  pressure. 
The  history  in  these  cases  is  usually  so  clear  and  the  symptoms  so  pro- 
nounced that  there  is  little  difficulty  in  making  the  proper  diagnosis  unless 
the  surgeon  is  called  too  late,  because  the  patient's  primary  injury  has  been 
overlooked  on  account  of  the  apparent  slightness  of  its  character. 

The  treatment  in  these  cases  must  be  applied  at  once,  for  if  it  is  neg- 
lected the  patient's  condition  will  soon  become  hopeless. 

Details  of  Operation. 

The  danger  of  infection  of  the  meninges  is  greatly  reduced  by  thorougly 
shaving  the  entire  scalp  before  the  commencement  of  the  operation.  If 
only  a  small  portion  of  the  surface  is  shaved  it  is  likely  that  during  some 
part  of  the  operation  some  one  will  carry  infectious  material  from  the 
remaining  portion  of  the  scalp  to  the  wound  and  thus  cause  an  infection, 
which  in  these  cases  is  always  serious.  If  the  entire  scalp  has  been  care- 
fully shaved  the  further  disinfection  is  no  more  difficult  than  disinfection 
of  the  skin  in  any  other  portion  of  the  body. 

If  the  point  of  injury  can  be  distinctly  located  in  the  course  of  one 
of  the  principal  branches  of  the  middle  meningeal  artery,  the  point  of  opera- 
tion can  be  determined  in  this  manner.  If  this  cannot  be  done  it  will  become 
necessary  to  expose  first  one  and  then  the  other  of  the  principal  branches 
of  this  vessel,  provided  the  first  attempt  fails,  or  it  may  be  better  to  expose 
both  branches  at  once  by  making  an  osteoplastic  resection  of  a  portion  of 
the  skull,  covering  both  the  anterior  and  the  posterior  branches  of  the  mid- 
dle meningeal  artery.  The  following  guide  will  suffice  to  locate  these 
branches : 

The  anterior  branch  crosses  a  point  one  and  one-fourth  inches  back- 


Fig.  8. 

DE  VILBISS  FORCEPS. 

Fig.  G  represents  the  forceps  when  partly  closed.  Fig.  7  indicates  the  proper 
manner  of  holding  the  forceps  in  the  left  hand  while  introducing  the  punch  (c) 
through  the  trephine  opening  and  sliding  it  through  the  groove  in  the  skull,  which  has 
already  been  made,  the  right  hand  being  employed  entirely  for  the  purpose  of  closing 
the  handles  and  thus  forcing  the  punch  through  the  bone  within  its  grasp.  Fig.  8 
represents  the  proper  form  of  trephine  to  be  used.  Its  conical  shape  prevents  injury 
to  the  dura,  because  it  locks  the  trephine  the  moment  the  bone  is  cut  through,  be- 
cause this  at  once  causes  all  of  the  lateral  teeth  to  become  imbedded  in  the  hole  which 
has  been  cut. 


SURGERY  OF   THE  HEAD  IO3 

ward  and  upward  from  the  external  angular  process  of  the  frontal  bone. 
The  posterior  branch  crosses  a  point  at  which  this  line  crosses  a  line  drawn 
vertically  from  the  anterior  edge  of  the  mastoid  process.  An  opening  can 
be  made  at  these  points  by  means  of  a  trephine  one-half  inch  in  diameter; 
the  instrument  should,  however,  be  conical  in  shape  so  that  as  soon  as  the 
inner  table  of  the  skull  has  been  perforated  by  it  the  instrument  is  stopped 
automatically  from  penetrating  deeper  and  causing  an  injury  to  the  dura. 
It  is  usually  best  to  make  an  oval  skin  flap  covering  the  area  traversed  by 
both  the  posterior  and  the  anterior  branches  of  the  middle  meningeal  artery, 
so  that  if  the  injury  is  not  found  in  the  anterior  branch,  which  is  most  com- 
monly the  seat  of  trouble,  an  elliptical-shaped  flap  of  the  parietal  bone  may 
be  cut  loose  by  means  of  DeVilbiss  forceps.  In  this  way  much  time  can  be 
saved  and  the  surface  can  be  so  thoroughly  exposed  that  no  error  is  possi- 
ble, as  shown  in  Plate  I. 

In  making  the  resection  of  the  skull  the  size  and  form  of  the  flap  may 
be  regulated  by  directing  the  instrument.  A  flap  sufficiently  large  to  cover 
the  space  occupied  by  the  posterior  and  anterior  branches  of  the  middle 
meningeal  artery  can  be  cut  with  the  DeVilbiss  forceps  in  a  very  short  time, 
usually  less  than  ten  minutes  being  required  for  this  purpose.  It  is,  how- 
ever, necessary  to  bear  in  mind  the  technique  required  in  the  use  of  these 
forceps.  The  cutting  portion  of  the  forceps  should  be  introduced  through 
the  originally  provided  opening,  and  then  it  should  be  slid  along  the  cut 
which  has  already  been  made  until  the  end  is  engaged  under  the  portion 
of  the  skull  to  be  severed.  Unless  this  precaution  is  taken  the  work  will 
progress  very  slowly.  The  small  bridge  at  the  base  of  the  bone-flap  is 
weakened  by  the  application  of  a  few  strokes  of  the  chisel  and  then  it  is 
fractured  by  inserting  a  strong  chisel  opposite  this  point  and  elevating  the 
flap.  The  bleeding  vessel  is  now  exposed  and  ligated  by  passing  about  it  a 
fine  catgut  ligature  threaded  in  a  needle,  the  clot  is  sponged  away,  the  bone 
flap  is  replaced,  and  the  overlying  skin  is  sutured.  If  there  is  still  some 
oozing  after  the  injured  portion  of  the  meningeal  artery  has  been  ligated 
it  is  wise  to  place  a  small  capillary  drain  underneath  the  flap  to  prevent 
re-accumulation  of  blood. 

CHRONIC   SUB-DURAL   HEMORRHAGE. 

Occasionally  the  hemorrhage  from  some  very  small  ruptured  branch 
of  the  meningeal  artery  is  so  slow  that  no  immediate  symptoms  are  dis- 
covered for  days  or  weeks  or,  as  in  one  of  our  own  cases,  for  three  months. 

The  first  symptoms  may  consist  of  only  slight  headaches,  with  a  feel- 
ing of  pressure  in  the  region  where  the  blood  is  accumulating.  Later  the 
pain  becomes  more  severe,  but  frequently  the  injury  to  the  head  has  been 
forgotten  by  the  patient  and  his  friends,  so  that  the  surgeon  does  not 
receive  any  information  regarding  this  most  important  element  of  the  his- 
tory. Then  pressure  symptoms  occur  in  the  form  of  paralysis,  and  if  the 
pressure  is  over  the  area  of  the  speech  center  there  may  be  at  first  some 
slight  difficulty  in  articulation,  which  becomes  more  and  more  marked  until 
complete  aphasia  occurs.  Later  the  irritation  caused  by  the  pressure  may 
result  in  mania.  Aside  from  these  symptoms  the  typical  evidences  of  in- 
creased intra-cranial  pressure  may  be  noticed.  This  usually  gives  rise  to  a 
diagnosis  of  intra-cranial  tumor  unless  the  condition  is  attributed  to  the 
original  injury. 


IO4  SURGERY  OF  THE  HEAD 

Technique. 

The  method  of  operating  is  the  same  as  for  ligation  of  the  middle 
meningeal  artery  as  regards  the  formation  of  skin  and  bone  flaps.  When 
the  dura  has  been  exposed  it  will  be  found  to  bulge  and  no  pulsation  can  be 
detected. 

An  incision  of  the  dura  will  evacuate  either  clotted  blood  or  serum  or 
both.  In  cases  in  which  the  injury  has  occurred  a  considerable  time  before 
the  operation  the  cavity  is  likely  to  contain  only  serum,  which  is  usually 
colored  with  blood  pigment. 

This  accumulation  may  vary  in  size  from  a  capacity  of  a  few  cc.  to 
500  cc.  or  more. 

It  is  surprising  how  quickly  the  symptoms  disappear,  even  in  cases  that 
have  suffered  from  cerebral  compression  for  a  considerable  period,  pro- 
vided the  increase  in  pressure  was  very  gradual. 

The  wound  in  the  dura  should  be  closed  with  fine  catgut  sutures.  Some 
silkworm  gut  strands  or  some  folded  gutta  percha  tissue  should  be  used 
for  drainage  from  one  angle  of  the  wound  and  a  large  external  dressing 
should  be  applied.  In  one  of  our  cases  there  was  a  slight  re-accumulation 
probably  from  secretion  from  the  walls  of  the  space  in  which  the  original 
accumulation  had  taken  place. 

Simply  reopening  one  angle  of  the  wound  very  slightly  permitted  this 
fluid  to  escape  and  then  the  recovery  progressed  uninterruptedly  and  the 
patient  remained  permanently  well. 

Important  To  Recognize  the  Indications. 

It  is  really  very  important  to  bear  this  condition  in  mind  in  dealing 
with  patients  suffering  from  headaches  and  other  pressure  symptoms,  be- 
cause most  of  the  reported  cases  suffered  for  a  long  time  before  a  diagnosis 
was  made.  The  condition  is  undoubtedly  never  recognized  in  many  cases. 
If  the  fluid  accumulates  more  rapidly  these  patients  die  from  cerebral  com- 
pression. 

LACERATION  OF  BRAIN  TISSUE. 

In  connection  with  the  compound  comminuted  fractures  of  the  skull 
more  or  less  laceration  of  brain  tissue  is  common.  After  removing  the 
loose  fragments  of  bone  and  discarding  those  that  have  been  soiled  and 
preserving  the  others  in  warm  normal  salt  solution,  the  ragged  portions 
of  brain  tissue  which  project  through  the  dura  should  be  cut  away  with 
very  sharp  scissors  and  the  tears  in  the  dura  should  be  approximated  with 
fine  catgut  sutures.  Then  the  clean  fragments  of  bone  are  placed  over 
this  surface  and  the  periosteum  sutured  over  these.  The  wound  is  drained 
with  strands  of  silkworm  gut  or  gutta  percha  tissue  and  a  large  dressing 
is  applied.  In  all  of  these  cases  if  conditions  are  not  favorable  for  imme- 
diately doing  the  required  operative  work,  it  is  well  to  saturate  the  scalp 
with  compound  tincture  of  iodine  and  to  apply  an  aseptic  dressing  after 
controlling  the  hemorrhage  and  then  to  send  the  patient  to  a  hospital,  where 
the  required  operative  care  can  be  given  at  the  earliest  possible  moment. 

DEPRESSED  FRACTURES  OF  THE  SKULL. 

Do  Not  Delay  Elevating. 

In  the  treatment  of  acute  injuries  of  the  skull,  it  is  important  to  remem- 


SURGERY  OF  THE  HEAD  IO5 


her  that  depressed  fractures,  although  frequently  not  accompanied  ^ 
serious  symptoms  at  the  time  of  the  injury,  are  likely  to  result  in  exceedingly 
serious  late  conditions,  unless  the  difficulty  is  relieved  quickly  after  the 
injury.  The  irritation  resulting  from  a  depressed  fracture  frequently  gives 
rise  to  epilepsy  at  some  time  after  the  occurrence  of  the  injury.  In  order 
to  prevent  this,  it  is  important  in  every  case  in  which  there  is  a  depressed 
fracture  to  elevate  this  at  once,  which  can  be  accomplished  by  exposing  the 
seat  of  the  fracture  by  an  incision  through  the  scalp,  the  latter  having 
been  shaved  as  indicated  in  connection  with  previous  operations  on  the 
part.  If  the  fracture  is  comminuted  a  small  portion  of  bone  can  usually 
be  removed  by  the  introduction  of  the  sharp  edge  of  a  chisel,  and  with  the 
use  of  this  instrument,  together  with  the  sequestrum  forceps,  it  is  usually 
possible  to  adjust  the  portions  of  the  depressed  fracture  very  accurately. 
If  this  cannot  be  done  it  is  safer  to  sacrifice  some  portions  of  the  skull  than 
to  leave  any  depressed  part  to  irritate  the  meninges. 

If  an  injury  is  found  in  the  dura  this  should  be  sutured  with  fine  catgut. 
After  the  skull  has  been  carefully  adjusted  the  scalp  is  sutured  over  this 
with  or  without  capillary  drainage,  according  to  the  amount  of  oozing  that 
remains.  Care  should  be  taken  to  sacrifice  as  little  as  possible  of  the  skull, 
and  in  simple  fractures  fragments  may  be  replaced  with  safety,  although 
they  may  be  entirely  separated  both  from  the  dura  and  the  periosteum.  In 
compound  fractures  the  same  plan  of  treatment  must  be  pursued,  with  the 
addition  of  very  careful  disinfection,  the  removal  of  all  fragments  of  the 
skull  which  may  have  become  infected  in  the  least  and  the  use  of  drainage 
in  all  of  these  cases. 

Choice  of  Bone  Chisel. 

In  all  chiseling  operations  upon  the  skull  and  elevations  of  fragments, 
the  ordinary  carpenter's  chisel  and  a  mallet,  such  as  the  one  used  by  wood 
carvers,  are  of  the  greatest  convenience.  Most  bone  chisels  which  can  be 
obtained  in  instrument  stores  are  practically  useless  for  this  purpose, 
because  they  are  either  clumsy  or  difficult  to  handle,  while  the  carpenter's 
chisel  can  be  used  with  ease  by  any  one  who  has  the  least  manual  capacity. 
A  convenient  amount  of  bone  may  be  cut  away  in  a  few  moments  with 
this  instrument  and  the  form  of  the  incision  in  the  bone  can  be  easily  con- 
trolled. The  chisels  are  so  sharp  that  their  use  does  not  give  rise  to  any 
severe  concussion.  This  is  especially  true  if  the  edge  of  the  chisel  is  held 
nearly  parallel  with  the  surface  of  the  bone.  A  number  of  chisels  should 
be  at  hand,  so  that  if  any  defect  occurs  in  one  it  may  be  laid  aside  and 
another  substituted  at  once. 

TREPHINING  FOR  THE  CURE  OF  EPILEPSY. 

In  cases  in  which  epilepsy  follows  fracture  of  the  skull  and  in  which 
it  is  possible  to  determine  positively  from  focal  symptoms  that  there  is  a 
definite  point  in  the  cerebrum  which  is  being  irritated  by  some  condition 
resulting  from  the  fracture,  it  may  be  proper  to  remove  a  portion  of  the 
skull  overlying  the  area  which  has  been  determined  and  to  remove  any 
irritating  substance  it  may  be  possible  to  discover.  Occasionally  an 
exostosis  has  developed  from  the  line  of  fracture  in  the  form  of  a  sharp 
spicule  of  bone,  or  a  fragment  may  have  been  displaced  at  the  time  of  the 
original  injury  and  may  extend  into  the  substance  of  the  brain,  or  a  small 


1O6  SURGERY   OF   THE   HEAL) 

cyst  may  have  formed  on  the  under  surface  of  the  dura  or  the  latter  may 
be  markedly  thickened,  or  there  may  be  a  considerable  amount  of  cicatricial 
tissue  in  the  brain  substance,  resulting  from  the  healing  of  a  tear. 

All  of  these  may  readily  be  relieved  by  excision,  but  unfortunately 
this  does  not  result  in  a  cure  in  many  of  the  cases  of  epilepsy  which  are 
unquestionably  traumatic  in  origin. 

Importance  of  After-treatment. 

In  the  after  treatment  of  these  cases  that  have  been  treated  surgically 
it  is  important  to  insist  upon  good  hygienic  and  dietetic  care  for  a  long" 
period  of  time  following  the  operation.  It  is  also  well  to  give  these  patients 
as  nearly  as  possible  a  salt-free  diet  and  to  have  them  use  a  very  small 
amount  of  bromide  of  soda,  in  place  of  table  salt,  on  their  food.  All  excite- 
ment, overwork,  exposure  to  heat,  and  every  other  form  of  physical  and 
mental  irritation  should  be  avoided.  The  use  of  thyroid  extract  may  be 
tried  by  giving  from  three  to  four  doses  daily  of  three  to  five  grains. 

We  have  used  this  form  of  'treatment  in  many  cases,  and  although  its 
results  have  been  disappointing  time  and  again,  still  there  have  been  a 
sufficient  number  of  cases  in  which  the  results  were  satisfactory  to  make 
the  effort  worth  while. 

This  is  true  especially  of  the  cases  in  which  we  have  been  able  to  direct 
the  diet  and  hygiene  of  the  patient  subsequent  to  the  operation. 

Many  of  these  patients  have  acquired  careless  or  erratic  habits  of  life 
and  especially  unfavorable  habits  of  diet,  both  as  regards  time  of  eating  and 
quantity  and  character  of  food.  \Ye  have  observed  patients  who  remained 
perfectly  well  for  months  or  years  who  had  a  recurrence  of  an  epileptic 
seizure  after  eating  an  unreasonable  amount,  or  after  eating  a  large  meal 
when  exhausted  after  a  day's  labor. 

One  of  these  cases  remained  well  until  he  worked  beyond  his  strength 
for  a  number  of  days  in  the  hay  field,  after  having  been  well  for  two  years 
following  an  operation  for  the  relief  of  a  depressed  fracture  of  the  skull. 
This  case  had  suffered  from  epilepsy  for  several  years  previous  to  the  opera- 
tion. 

It  seems  clear  that  although  the  local  irritation  in  the  cortex  may  have 
been  relieved  by  the  operation  any  one  of  a  number  of  correlating  influ- 
ences affecting  the  patient's  general  condition  may  be  the  cause  of  a  recur- 
rence, hence  the  'wisdom  of  careful  control  of  the  patient  after  operation. 

TUMORS  OF  THE  SKULL. 

Tumors  of  the  skull,  which  result  from  invasion  of  tumors  of  the  scalp, 
arc  the  only  ones  that  we  have  operated  with  permanent  recover}-  of  the 
patient.  In  these  instances  the  most  satisfactory  results  have  been  obtained 
by  removing  the  tumor  of  the  >calp,  together  with  a  large  area  of  surround- 
ing, apparently  healthy  tissue,  and  then  applying  to  the  surface  of  the  entire 
area  of  exposed  skull,  and  also  to  the  edges  of  the  scalp  wound,  large 
cautery  irons  heated  to  red  heat,  being  careful,  however,  not  to  leave  the 
iron  in  contact  at  any  one  point  long  enough  to  cook  the  underlying  men- 
inges  or  brain.  The  Paqnelin  cauterv  does  not  hold  a  sufficient  amount  of 
heat  to  be  of  much  use  for  this  purpose  as  the  large  cautery  irons,  prefer- 
ably ordinary  soldering  irons,  heated  in  a  large  gas  or  alcohol  flame. 

A  dry  dressing  is  then  applied  to  the  wound,  which   is  later  dressed 


SURGERY   OF   THE  HEAD  IO7 

antiseptically  until  the  granulation  tissue  causes  the  sequestrum  to  loosen, 
so  that  it  may  be  removed  easily.  Then  the  entire  surface  is  covered  with 
Thiersch  grafts. 

PRIMARY   TUMORS   OF  THE  SKULL. 

When  these  are  quite  circumscribed  they  should  be  removed  with  the 
overlying  skin  and  the  underlying  dura ;  at  least  two  cm.  of  skin  should  be 
removed  in  every  direction  beyond  the  edge  of  the  tumor. 

Personally,  we  have  never  encountered  any  primary  tumors  of  the  skull 
in  which  it  was  possible  to  make  a  complete  removal  of  the  growth  by  this 
or  by  any  other  method,  but  this  does  not  make  such  a  condition  impossible, 
and  it  is  quite  conceivable  to  obtain  permanent  results  in  cases  coming 
tinder  treatment  reasonably  early. 

TUBERCULOSIS  OF  THE  SKULL. 

This  condition  is  not  very  uncommon  and  the  results  of  surgical  treat- 
ment are  relatively  favorable  if  two  requirements  are  observed,  viz.,  ist, 
careful  removal  of  every  portion  of  the  infected  tissue,  and,  2nd,  careful 
control  of  the  diet  and  hygiene  of  the  patient  after  the  operation. 

In  these  cases  one  should  never  attempt  the  removal  of  the  diseased 
tissue  by  means  of  the  curette  through  the  sinuses  in  the  scalp,  a  method 
which  had  been  practised  unsuccessfully  in  every  case  that  has  come  under 
our  care  to  the  present  time.  If  a  radical  operation  is  not  feasible  for  the 
time  being,  the  patient  should  be  placed  under  careful  d;etetic  and  hygienic 
treatment  temporarily  and  the  sinuses  should  be  injected  full  of  Beck's 
bismuth  paste,  consisting  of  one  part  of  bismuth  subnitrate  and  two  parts 
of  yellow  vaselin.  This  should  be  repeated  from  one  to  three  times  per 
week,  according  to  the  progress  of  the  case. 

The  discharge  from  the  sinuses  will  become  aseptic  after  a  short  time 
and  complete  healing  may  ensue,  although  my  personal  experience  with  the 
paste  in  this  part  of  the  body  has  not  been  sufficient  to  determine  this  with 
certainty. 

Technique. 

It  is  highly  important  to  make  a  large  incision  in  order  that  every 
portion  of  the  diseased  bone  may  be  exposed  after  the  periosteum  has  been 
reflected,  together  with  the  skin  flap.  Beginning  at  the  opening  of  any  one 
of  the  sinuses  of  the  skull,  the  outer  table  is  chiseled  away  with  a  very  sharp 
carpenter's  chisel.  In  order  to  find  all  portions  of  the  diseased  bone  it  is 
important  to  observe  the  granulation  tissue  projecting  from  the  cut  surface 
of  the  bone  after  carefully  sponging  away  the  blood.  Sharp  gnawing 
bone  forceps  are  very  useful  in  this  operation,  but  there  is  no  instrument 
of  as  much  value  as  the  sharp  carpenter's  chisel  and  gouge. 

After  all  of  the  sinuses  have  been  followed  and  every  portion  of  the 
infected  tissue  has  been  cut  or  curetted  away  so  that  there  is  at  no  point 
any  granulation  tissue  to  be  found,  the  surface  is  dried  and  then  saturated 
for  ten  minutes  with  95  per  cent  carbolic  acid :  then  it  is  covered  with 
strong  alcohol  until  the  white  color  caused  by  the  carbolic  acid  has  entirely 
disappeared,  after  which  it  is  thoroughly  covered  with  strong  compound 
tincture  of  iodine.  A  little  silkworm  gut  or  rubber  tissue  drain  is  placed 
and  the  wound  is  sutured. 


IO8  SURGERY  OF   THE  HEAD 

In  the  rare  cases  in  which  the  overlying  scalp  has  been  destroyed  by 
the  disease  a  sufficient  amount  of  the  surrounding-  tissue  is  removed  by  the 
actual  cautery  to  insure  a  complete  removal  of  all  of  the  diseased  tissue 
and  then  the  entire  surface  is  covered  with  Thiersch  skin  grafts,  after  the 
bone  surface  has  become  covered  with  granulation  tissue. 

CLOSURE  OF  BONY  DEFECTS  IN  THE  SKULL. 

In  case  a  considerable  portion  of  the  skull  has  been  entirely  removed, 
it  may  become  desirable  to  close  this  defect  in  order  to  protect  the  patient 
against  an  accidental  injury  of  the  exposed  portion  of  the  brain.  This 
becomes  necessary  only  in  cases  in  which  the  defect  is  very  large,  or  in 
which  it  gives  rise  to  some  form  of  annoyance  to  the  patient.  The  latter 
may  feel  a  sense  of  insecurity  or  he  may  be  annoyed  by  extreme  heat  or 
cold,  or  there  may  be  a  sensation  of  pain,  or  the  constant  pulsation  of  the 
area  may  give  rise  to  a  feeling  of  nervousness,  or  the  irritation  may  occasion 
attacks  of  epilepsy.  In  either  case  the  defect  may  be  closed  by  the  inser- 
tion of  a  foreign  substance  between  the  scalp  and  the  dura,  such  as  a  thin 
plate  of  celluloid,  which  may  be  boiled  and  cut  the  exact  shape  of  the 
defect,  with  a  sufficient  margin  to  hold  the  plate  when  inserted  underneath 
the  rim  of  the  defect  in  the  skull.  If  such  a  plate  is  implanted  aseptically  it 
will  remain  for  an  indefinite  period  of  time  without  giving  rise  to  any 
annoyance.  We  have  used  such  plates  in  a  number  of  cases  with  perfect 
satisfaction.  It  must  be  remembered,  however,  that  in  cases  of  epilepsy  the 
number  of  cures  from  the  use  of  such  a  plate  is  relatively  very  small. 

An  autoplastic  bony  closure  may  be  accomplished  by  cutting  an  oval 
flap  of  the  scalp  directly  along  the  side  of  the  defect  with  a  pedicle  sufficient 
to  supply  circulation  to  the  flap;  then  cutting  a  second  flap  of  the  same, 
shape  directly  covering  the  defect  and  having  its  pedicle  in  the  opposite 
direction  from  the  one  first  made.  The  second  flap  is  dissected  loose,  leav- 
ing the  dura  in  place.  The  latter  is  then  loosened  from  its  attachment  to 
the  rim  of  the  opening  and  with  a  thin,  broad  chisel  a  thin  layer  of  the  skul! 
underlying  the  first  flap  is  chiseled  loose  and  left  in  contact  with  the  flap. 
The  latter  is  then  transplanted  over  the  defect  in  the  skull  and  sutured 
in  place,  and  the  second  flap  is  then  sutured  into  the  space  from  which 
the  first  flap  has  been  removed.  In  this  manner  all  portions  of  the  scalp 
will  remain  covered  with  hair  and  the  bone  carried  with  the  first  flap  will 
effectually  close  the. defect  in  the  skull. 

Usually  this  operation  has  been  performed  by  removing  the  scalp  from 
the  surface  of  the  defect  and  transplanting  a  flap  from  a  neighboring  por- 
tion of  the  skull  and  then  covering  the  defect  with  skin  grafts,  but  the 
method  which  has  just  been  described  is  very  much  more  satisfactory,  as 
it  does  not  leave  a  portion  of  the  scalp  without  its  hairy  covering. 

CEREBRAL  LOCALIZATION. 

In  order  to  intelligently  approach  surgical  conditions  within  the  cavity 
of  the  skull,  affecting  portions  of  the  brain,  it  is  absolutely  necessary  to 
have  a  clear  conception  of  cerebral  localization. 

"\Ye  have  personally  always  depended  upon  some  one  of  our  colleagues 
whose  opinion,  from  a  neurological  standpoint,  was  so  vastly  superior  to 


Fig.  9. 

DIAGRAM  SHOWING  AREAS  OF  CEREBRAL  LOCALIZATION. 
(Taken  from  the  original  drawings  by  Prof.  Chas.  K.  Mills.) 


Fig.  10. 

DIAGRAM  SHOWING  AREAS  OF  CEREBRAL  LOCALIZATION. 
(Taken  from  the  original  drawings  by  Prof.  Chas.  K.  Mills.) 


SURGERY   OF   THE  HEAD  III 

our  own  that  we  have  never  felt  called  upon  to  rest  upon  our  own  judgment 
in  the  matter  of  locating  cerebral  conditions  independently. 

We  have,  however,  always  confirmed  these  diagnoses  before  opening 
the  skull,  simply  for  the  purpose  of  having  a  reasonable  basis  upon  which 
to  share  the  responsibility. 

For  practical  purposes  it  seems  best  to  obtain  a  mental  picture  of  the 
entire  brain,  and  to  associate  the  various  areas  with  their  functions,  and 
then  to  transfer  these  areas  to  the  surface  of  the  skull. 

The  accompanying  drawings  by  Prof.  Chas.  K.  Mills,  are  exceedingly 
simple  and  clear,  and  we  have  found  them  most  useful  in  our  own  clinical 
work. 

There  are  certain  general  facts  concerning  cerebral  localization  which 
must  always  be  borne  in  mind  in  diagnosing  brain  lesions,  which  are,  how- 
ever, so  well  known  that  it  is  scarcely  proper  to  mention  them  in  this  place. 
We  refer  particularly  to  the  fact  that,  with  the  exception  of  certain  muscles 
like  the  orbiculares  oculi,  those  of  mastication,  the  larynx,  the  pharynx,  etc., 
the  muscles  of  the  body  are  controlled  by  the  motor  areas  of  the  opposite 
cerebral  hemisphere.  There  may,  however,  be  a  tumor,  abscess,  or  blood 
clot,  in  one  hemisphere,  exerting  a  sufficient  amount  of  pressure  transversely 
upon  the  other  side  'to  cause  symptoms  originating  in  the  opposite  hemis- 
phere, so  that  symptoms  of  paralysis  in  these  rare  cases  will  be  found  on 
the  side  on  which  the  brain  lesion  exists. 

It  is  further  important  to  remember  that  these  areas  of  localization 
are  not  definitely  circumscribed,  but  that  they  overlap  each  other. 

TUMORS  OF  THE  BRAIN. 

The  removal  of  a  fibroma,  gumma,  and  cysts  from  the  brain  is  fre- 
quently followed  by  permanent  recovery  of  the  patient,  and  as  it  is  usually 
impossible  to  make  a  differential  diagnosis  between  these  and  malignant 
growths  an  attempt  at  their  removal  is  of  course  justifiable,  because  the 
consequent  pressure  from  benign  growths  will  result  seriously  to  the 
patient,  even  if  it  does  not  shortly  destroy  him.  Therefore  the  patient  who 
is  suffering  from  a  non-malignant  tumor  has  everything  to  gain  from 
operative  treatment,  while  the  one  who  suffers  from  the  presence  of  a 
malignant  growth  has  nothing  to  lose  and,  as  will  be  presently  indicated  in 
the  discussion  of  the  decompression  operation,  even  this  class  of  patients 
has  much  to  gain. 

Gushing,  Mills,  Krause  and  Horsier  have  demonstrated  the  possibility 
of  exact  localization  so  constantly  and  so  many  times  that  one  can  usually 
be  positive  concerning  the  location  of  cerebral  tumors.  In  our  experience 
Rothstein  has  been  able  to  indicate  the  precise  location  of  cerebral  growths, 
so  that  it  has  been  possible  for  us  to  make  an  osteoplastic  flap  in  each 
instance  from  which  the  growth  could  be  reached. 

These  flaps  are  formed  according  to  the  method  to  be  described  pres- 
ently in  connection  with  the  operation  for  removal  of  the  Gasserian  gang- 
lion. 

Experience   and  Special  Training. 

At  this  point  it  may  be  well  to  state  that  it  is  not  proper  to  undertake 
this  operation  unless  a  surgeon  lias  had  experience  in  the  capacity  of  assist- 


112  SURGERY  OF  THE  HEAD 

ant  to  a  skillful  and  careful  master.  It  is  quite  different  from  operating  for 
cerebral  pressure,  due  to  the  presence  of  a  blood-clot  caused  by  hemorrhage 
from  a  torn  vessel,  which  is  really  an  emergency  operation  that  cannot  wait 
for  a  surgeon  with  special  training. 

Technique. 

Many  of  these  patients  lack  resistance  and  consequently  the  surgeon 
with  the  greatest  experience  and  skill,  and  the  best  judgment,  is  none  too 
well-equipped  for  performing  a  successful  operation.  In  many,  it  is  best 
to  make  the  skin  and  bone  flap  at  the  first  operation,  and  then,  a  few  days 
later,  when  the  patient  has  recovered  from  the  shock  of  this  step,  to  com- 
plete the  work.  In  the  meantime  a  piece  of  aseptic  gauze  is  placed  under- 
neath the  flap  and  the  latter  is  held  in  place  by  means  of  a  few  sutures  and 
the  entire  area  covered  with  an  aseptic  dressing. 

With  some  experience  it  is  possible  to  determine  which  cases  should 
be  treated  in  one  and  which  in  two  stages. 

Hemorrhage  is  the  most  troublesome  feature  in  these  cases.  Only  a 
few  of  the  bleeding  vessels  can  be  controlled  with  hemostatic  forceps  and 
ligatures. 

Most  of  the  hemorrhage  must  be  controlled  with  gauze  pads  wrung  out 
of  hot  normal  salt  solution.  Even  very  severe  oozing  of  blood  from  the 
cut  brain  surface  can  usually  be  checked  by  holding  one  of  these  pads  in 
contact  with  the  bleeding  surface  for  a  period  of  five  minutes.  If  this  does 
not  suffice  in  giving  a  sufficient  amount  of  freedom  from  bleeding,  the  head 
of  the  table  should  be  elevated  in  order  to  place  the  body  at  an  angle  of 
from  40  to  60  degrees  with  the  horizontal  plane.  If  this  does  not  answer, 
the  wound  should  be  tamponed  with  sterile  gauze  and  the  operation  com- 
pleted after  an  interval  of  several  days. 

After  the  tumor  or  gumma  has  been  enucleated  the  cavity  should  be 
tamponed  with  a  gauze  pad  wrung  out  of  hot  normal  salt  solution,  and  this 
should  be  left  in  place  for  at  least  five  minutes.  If  hemorrhage  is  seen  to 
have  ceased  when  the  tampon  is  removed,  the  dura  and  skin  flaps  should  be 
closed,  with  the  exception  of  one  angle.  If  hemorrhage  has  not  ceased  the 
cavity  should  again  be  tamponed  with  an  aseptic  gauze  strip  and  one  strand 
should  be  passed  out  of  the  angle  of  the  wound,  which  is  to  be  closed  as 
above.  A  piece  of  gutta  percha  tissue  should  be  placed  about  the  part  of 
the  gauze  passing  through  the  dura  and  the  scalp  in  order  to  facilitate  its 
removal  a  few  days  later. 

DECOMPRESSION  OPERATION. 

In  many  cases  in  which  a  tumor  cannot  be  removed  and  in  Avhich  the 
patient  suffers  from  pressure  symptoms,  such  as  headache,  dizziness,  nausea, 
or  eye  symptoms,  as  indicated  by  impaired  vision  and  by  the  presence  of 
choked  disk  on  ophthalmoscopic  examination,  he  may  be  greatly  benefited 
by  the  removal  of  a  large  portion  of  the  skull. 

A  flap  is  made  preferably  directly  over  this  location  of  the  tumor.  It 
should  include  the  scalp  and  the  skull  together  with  the  dura.  If  an  explora- 
tion seems  indicated,  the  dura  is  not  primarily  removed,  but  a  crucial  incision 
is  made  in  the  dura,  which  is  later  closed  with  catgut  sutures,  if  a  removable 
tumor  is  found,  but  otherwise  it  is  cut  away  at  once.  The  bone  flap  is 


Fig.  11. 

CRANIAL  AREAS  FOR  OSTEOPLASTIC  OPERATIONS. 

These  areas   corresponding   to   the   regions   of  the   left   hemi    cerebrum    with 
definite  syndromes. 

(Taken  from  the  original  drawings  of  Prof.  Chas.  K.   Mills.) 


SURGERY   OF   THE   HEAD  115 

removed  entirely  and  the  skin  flap  is  closed,  with  the  exception  of  a  space 
of  about  one  cm.  at  one  angle.  \\  e  have  repeatedly  observed  a  marked  sub- 
jective improvement  in  the  vision  in  these  instances  and  a  disappearance  of 
all  of  the  other  symptoms  due  to  cerebral  pressure. 

In  most  cases  the  patients  have  remained  comfortable  after  this  opera- 
tion until  they  have  suddenly  died  from  hemorrhage  or  from  a  perforation 
of  a  lateral  ventricle,  but  in  each  one  the  patient  and  his  friends  have  agreed 
with  us  in  the  supposition  that  the  operation  had  been  of  marked  benefit  to 
the  sufferer. 

In  cases  in  which  it  is  plain  from  the  start  that  nothing  can  be  done 
except  a  decompression  operation,  it  is  perfectly  proper  that  this  be  under- 
taken by  a  surgeon  of  ordinary  skill  and  without  especial  experience,  but 
this  is  never  proper  in  cases  in  which  a  surgeon  with  greater  skill  might  be 
justified  in  removing  the  tumor. 

ABSCESS  OF  THE  BRAIN. 

What  has  been  said  with  regard  to  tumors  of  the  brain,  so  far  as  locali- 
zation and  approach  through  the  skull  are  concerned,  may  also  be  applied 
to  cerebral  abscess.  In  these  cases  there  is,  however,  usually  a  history  of 
suppuration,  most  commonly  in  the  middle  ear  and  mastoid  cells,  and  occa- 
sionally in  the  cavities  connected  with  the  nose. 

Nausea  is  usually  one  of  the  prominent  symptoms  and  there  is  often, 
but  not  always,  a  rise  in  temperature  at  some  period  during  the  day. 

After  exposing  the  dura  by  reflecting  a  bone  flap  there  may  be  an 
absence  of  pulsation  and  the  dura  may  be  edematous,  showing  that  the 
abscess  is  superficial.  In  this  event  a  simple  incision  with  the  insertion  of  a 
soft  rubber  drainage  tube  will  suffice. 

Should  the  abscess  not  be  superficial  the  deep  tissues  may  be  explored 
by  the  use  of  an  exploring  needle,  with  a  closed,  moderately-sharp  end  and 
•i  fair-sized  hole  in  the  side  near  the  end.  It  should  carry  an  obturator  in 
order  to  prevent  the  brain  tissue  from  clogging  the  canula.  From  time  to 
time  this  should  be  removed  and  an  aspirating  syringe  attached;  if  pus 
escapes  an  incision  should  be  made  along  the  side  of  the  exploring  trocar 
and  a  soft  rubber  drainage  tube  inserted.  A  notch  should  be  cut  in  the 
bone  flap  sufficiently  large  to  prevent  compression  of  the  tube,  which  should 
be  passed  out  at  this  point  and  the  wound  there  closed,  sufficient  space  being 
left  for  satisfactory  drainage.  Irrigation  should  not  be  employed.  The 
drainage  tube  should  be  left  in  place  until  the  discharge  of  pus  has  ceased. 

It  should  be  borne  in  mind  at  this  point  that  by  far  the  most  important 
duty  of  the  surgeon  is  to  prevent  the  formation  of  cerebral  abscesses  by 
early  radical  treatment  of  suppuration  wherever  it  may  occur,  but  especially 
suppuration  of  the  middle  ear  and  of  the  mastoid  cells. 

ABSCESS  OF  THE  MASTOID  CELLS. 

Patients  suffering  from  infection  of  the  mastoid  process  usually  give  a 
preliminary  history  of  some  infectious  disease  affecting  the  tonsils.  This  is 
followed  by  an  infection  of  the  cavity  of  the  middle  ear.  The  abscess  of 
the  middle  ear  may  have  been  drained  spontaneously  by  a  perforation  of 
the  drum  or  the  latter  may  have  been  incised,  but  there  is  usually  a  history 
of  recurrence  of  this  infection  or  a  continuous  infection  indicated  by  the 


Il6  SURGERY  OF   THE  HEAD 

presence  of  interrupted  or  continuous  discharge  from  the  ear.  Following 
this  pain  appears  behind  the  ear  in  the  region  of  the  mastoid  process.  Fre- 
quently this  pain  subsides  when  the  discharge  reappears,  indicating  that 
drainage  has  been  established  from  the  mastoid  process  through  the  middle 
ear.  In  other  cases  the  pain  steadily  increases  and  is  presently  followed  by 
the  occurrence  of  edema  over  the  region  of  the  mastoid  process,  which  may 
extend  downwards  upon  the  neck  along  the  course  of  the  deep  jugular  vein. 
In  rare  instances  there  may  be  fluctuation  in  the  region  of  the  mastoid 
process,  or  even  perforation  of  the  abscess,  but  usually  the  resistance  of  the 
periosteum  covering  this  process  is  sufficient  to  prevent  these  evidences  from 
appearing. 

Still  later  the  patient  may  suffer  from  diffuse  headaches  extending  over 
a  more  or  less  extensive  portion  of  the  head,  usually  radiating  from 
the  site  of  the  infected  process.  Still  later  the  patient  may  become  comatose 
or  nausea  and  vomiting  may  appear,  which  may  be  followed  sooner  or  later 
by  coma  and  death.  The  explanation  of  the  condition  described  lies  in  the 
fact  that  the  infection  has  extended  from  the  cavity  of  the  middle  ear  into 
the  mastoid  cells.  It  has  then  progressed  outward  to  the  periosteum,  or 
through  this,  or  it  has  extended  inward  underneath  the  dura  and  has  caused 
a  more  or  less  diffuse  meningitis,  sometimes  accompanied  by  a  subdural 
abscess,  or  it  may  have  extended  into  the  brain — giving  rise  to  a  cerebral 
abscess.  These  patients  are  usually  seen  by  the  practitioner  before  the 
infection  has  advanced  beyond  the  mastoid  cells,  and  it  is  at  this  time  that 
the  greatest  amount  of  benefit  may  come  from  surgical  intervention.  At 
this  time  the  operation  is  safe,  it  can  be  performed  by  any  surgeon  with 
ordinary  skill,  and  the  patient  is  not  likely  to  suffer  secondarily  as  a  result. 
It  is  quite  different  if  the  operation  be  postponed  until  there  has  been  a  con- 
siderable extension  of  the  infection.  In  such  event  it  is  scarcely  proper  for 
any  one  who  has  not  had  extensive  experience  in  brain  surgery  to  operate 
upon  these  patients,  and  even  with  the  greatest  skill  the  proportion  of 
recoveries  is  but  slight.  In  cases  operated  at  the  proper  time,  that  is,  dur- 
ing the  early  part  of  the  infection,  the  drainage  which  can  easily  be  estab- 
lished will  prevent  the  further  infection  of  the  deeper  structures,  and  con- 
sequently will  make  a  more  extensive  operation  unnecessary. 

It  would  seem  that  the  presence  of  pain,  together  with  even  a  slight 
amount  of  edema  in  the  region  of  the  mastoid  process,  the  pain  being  in- 
creased upon  pressure,  and  in  any  case  in  which  there  is  a  history  of  pre- 
vious infection  of  the  middle  ear,  would  be  a  distinct  indication  for  an  opera- 
tion. 

Technique.  , 

A  sufficient  amount  of  hair  should  be  shaved  off  in  the  vicinity  of  the 
mastoid  process  to  prevent  annoyance  in  applying  the  dressings  later  on  and 
to  prevent  the  hair  from  interfering  with  the  progress  of  the  operation. 
A  vertical  incision  is  then  made  directly  behind  the  ear,  one  and  one-half 
inches  in  length,  whose  center  is  at  a  point  one-fourth  of  an  inch  behind  and 
exactly  on  a  level  with  the  upper  margin  of  the  external  auditory  meatus. 
This  incision  should  extend  down  through  all  the  tissues  to  the  bone.  The 
periosteum  is  carefully  reflected  and  in  this  manner  the  mastoid  process  is 
exposed. 

If  the  points  which  have  just  been  mentioned  are  borne  in  mind,  the 
operation  may  be  performed  with  safety  by  any  one,  the  opening  into  the 


PLATE  I. 

TEMPORARY  RESECTION  OF  THE  SKULL. 

The  eliptical  flap  of  bone  a  remains  attached  to  the  flap  of  the  skin,  fascia,  muscle 
and  periosteum/".  The  latter  is  represented  somewhat  too  large  in  proportion  to  the 
size  of  the  bone  flap,  b  shows  the  middle  meniugeal  artery  with  its  anterior  and  pos- 
terior branches  e  and  d.  The  chisel  c  is  in  the  position  in  which  it  was  held  for  the 
purpose  of  severing  the  lower  attachment  of  the  bone  flap  after  the  horse-shoe  shaped 
groove  had  been  cut  with  the  De  Vilbiss  forceps.  The  entire  flap  should  be  placed  a 
little  higher  for  the  purpose  of  ligating  the  branches  of  the  middle  meniugeal  artery, 
and  somewhat  lower  for  the  removal  of  the  Gasserian  ganglion. 


SURGERY   OF   THE  HEAD  1 19 

mastoid  cells  being  made  by  means  of  an  ordinary  carpenter's  gouge  about 
one-half  inch  in  diameter. 

The  dangers  of  the  operation  are  in  opening  the  meninges  above  or 
invading  the  sinus  behind,  but  if  the  operator  makes  his  initial  opening  in 
ihe  mastoid  process  at  a  point  on  a  level  with  the  upper  margin  of  the 
external  auditory  meatus  and  one-fourth  of  an  inch  behind  the  posterior 
margin,  these  dangers  will  be  entirely  avoided.  After  the  mastoid  cells 
have  once  been  opened  the  opening  can  easily  be  enlarged  by  chiseling  in 
every  direction  from  this  central  point.  The  mastoid  cells  will  be  found  to 
contain  pus  in  various  quantities  from  a  few  drops  to  one-half  a  drachm  or 
more.  This  is  carefully  sponged  away  and  the  external  avenue  enlarged 
until  it  is  as  large  in  every  direction  as  the  greatest  diameter  of  the  under- 
lying cavity,  so  that  the  cavity  which  is  left  will  be  conical  in  shape,  with 
the  base  of  the  cone  directed  upward.  Care  should  be  taken  not  to  injure 
the  branch  of  the  facial  nerve  extending  along  the  edge  of  the  external 
auditory  meatus,  but  this  can  be  easily  done  by  simply  bearing  in  mind  the 
anatomical  position  of  this  nerve  and  working  away  from  it  with  the  chisel, 
instead  of  toward  it.  The  cavity  after  being  thoroughly  cleansed,  is  loosely 
tamponed  with  gauze  and  a  dressing  applied  over  it. 

The  dressing  should  be  renewed  at  first  every  da}-,  and  later  less  fre- 
quently, the  opening  in  the  mastoid  being  permitted  to  heal  from  the  bottom 
by  granulation.  In  advanced  cases,  and  in  those  in  which  the  infection  has 
existed  for  a  sufficient  time  to  insure  the  involvement  of  surrounding  tissues, 
a  more  extensive  operation  is  indicated,  but  this  should  be  performed  only 
by  those  experienced  in  surgery  upon  the  skull,  as  the  dangers  of  causing 
permanent  injury  are  much  greater,  and  the  necessity  of  the  operation  is  not 
so  urgent  as  in  acute  mastoiditis ;  consequently  such  operations  may  safely 
be  postponed  until  the  proper  preparations  can  be  made.  The  conditions 
are,  therefore,  quite  opposite  in  acute  mastoiditis,  the  operation  being  sim- 
ple. -;afe  and  strongly  indicated  at  once,  while  postponement  is  connected 
with  great  danger.  In  chronic  cases  the  operation  is  complicated,  difficult 
and  dangerous,  while  postponement  is  relatively  safe. 

MASTOID  OPERATION  IN  CHRONIC  CASES. 

It  is  difficult  to  describe  this  operation  so  that  it  can  be  performed 
safely  by  one  who  has  neither  accomplished  it  upon  the  cadaver  nor  has 
seen  it  done  upon  the  living  subject,  and  we  believe,  therefore,  that  this 
operation  is  not  justifiable  unless  the  surgeon  has  performed  it  upon  the 
cadaver. 

The  incision  is  the  same  as  in  the  operation  just  described;  the  perios- 
teum is  then  stripped  away  toward  the  external  auditory  meatus  and  a  blunt 
periosteotome  is  passed  down  between  the  bony  canal  of  the  external  audi- 
tory meatus  and  the  skin  lining  this  canal,  so  that  the  latter  is  loosened  down 
to  the  tympanum.  The  mastoid  antrum  is  then  opened,  as  described  in 
the  former  operation,  and  the  lower  layer  of  the  posterior  wall  of  the  bony 
portion  of  the  external  auditory  canal  is  removed  with  a  chisel,  so  that 
the  external  auditory  meatus  and  the  cavity  in  the  mastoid  form  a  contin- 
uous conical  opening.  The  cavity  of  the  middle  ear  is  then  opened  and 
the  hammer  and  anvil  are  removed  bv  means  of  forceps.  Great  care 
must,  of  .course,  be  exercised  to  protect  the  branch  of  the  facial  nerve 
which  passes  through  the  bony  wall  of  the  external  auditory  meatus.  The 


I2O  SURGERY  OF  THE  HEAD 

skin  lining  the  external  auditory  meatus  is  then  split  longitudinally  and 
spread  out  over  the  surface  of  the  newly-formed  cavity  for  the  purpose  of 
lining  this,  thus  increasing  the  size  of  the  external  auditory  meatus  greatly. 
It  is  held  in  place  by  means  of  a  tampon  of  iodoform  gauze. 

Use  of  Beck's  Bismuth  Paste. 

During  the  past  three  years  we  have  found  that  cases  in  which  the  infec- 
tion extends  down  the  Eustachian  tube  at  the  time  of  operation,  which 
causes  a  reinfection  of  the  wound  and  a  consequent  retardation  in  healing, 
excellent  results  may  be  obtained  from  dressing  the  cavity  with  Beck's 
bismuth  paste,  consisting  of  one  part  of  bismuth  subnitrate  and  two  parts 
of  yellow  vaseline,  applied  daily  at  first  and  less  frequently  later  on. 

Of  course  by  invariably  removing  the  infected  tonsils  and  the  adenoids 
which  are  located  about  the  osteum  of  the  Eustachian  tube  conditions  are 
established  which  are  favorable  for  the  spontaneous  healing  of  any  sup- 
purating surfaces  which  may  exist  in  this  tube.  We  have  never  injected 
Beck's  bismuth  paste  directly  into  the  Eustachian  but  it  is  claimed  that  this 
is  a  safe  and  beneficial  procedure  in  these  cases. 

REMOVAL  OF  THE  GASSERIAN    GANGLION. 

During  the  past  few  years  this  operation  has  been  performed  many 
times  by  many  surgeons  so  that  it  is  now  a  thoroughly  established  pro- 
cedure. Gushing  and  Frazier  and  Krause  have  discussed  their  special 
methods  which  they  have  applied  in  a  very  large  number  during  this  time 
and  for  those  who  are  particularly  interested  in  this  operation  it  is  well  to 
read  the  writings  of  these  authors. 

Before  performing  this  operation  it  is  most  important  to  do  it  upon 
the  cadaver  remembering  well,  however,  that  the  chief  difficulty  in  the 
operation  upon  the  living  subject  comes  from  the  fact  that  there  is  always 
a  certain  amount  of  blood  present  to  obscure  the  field,  and  that  for  this 
reason  the  simple  directions  which  follow  are  often  quite  difficult  to 
carry  out. 

Operative  Precautions  and  Technique. 

Preparatory  to  this  operation,  provision  should  be  made  against  the 
occurrence  of  an  injury  to  the  conjunctiva  from  the  fact  that  the  operation 
is  accompanied  by  paralysis  of  this  portion  which  prevents  the  eyelids  from 
protecting  the  conjunctiva  against  injury.  The  conjunctiva  is  therefore 
protected  temporarily  by  closing  the  eyelids  by  the  application  of  a  few 
fine  silk  sutures.  These  are  removed  at  the  end  of  from  one  to  two  weeks 
and  then  the  eye  is  protected  mechanically  by  the  use  of  a  properly  ad- 
justed shield.  The  next  step  consists  in  providing  for  a  bloodless  opera- 
tion. This  can  be  accomplished  by  exposing  the  common  carotid  artery 
and  applying  to  it  a  properly  constructed  clamp,  which  will  close  the  lumen 
of  this  vessel  without  crushing  the  intima.  The  pressure  should  be  care- 
fully graded,  so  that  this  object  may  be  accomplished  with  certainty.  This 
however,  is  possible  only  in  patients  in  whom  arterio-sclerosis  does  not 
exist  to  a  marked  degree.  The  hemorrhage  comes  partly  from  the  middle 
meningeal  artery  and  partly  from  the  dura,  and  both  of  these  sources  are 
of  course  controlled  by  this  temporary  closure  of  the  common  carotid.  A 
horseshoe-shaped  incision  one  and  one-half  inches  in  diameter  is  then  made 
with  its  convexity  upwards,  its  lower  branches  being  opposite  the  lower 


SURGERY  OF  THE  HEAD  121 

border  of  the  zygwnatic  process,  which  is  temporarily  resected,  the  center 
of  the  flap  corresponding-  to  a  point  opposite  the  Gasserian  ganglion.  The 
trephine  opening  is  then  made  similar  to  the  one  illustrated  for  the  ligation 
of  the  middle  meningeal  artery  and  then  by  means  of  the  DeVilbiss'  forceps 
a  groove  is  cut  in  the  bone  similar  in  shape  to  the  skin  flap,  only  slightly 
smaller.  The  base  of  this  flap  is  severed  by  means  of  a  few  strokes  of  the 
chisel,  and  then  it  is  elevated  and  laid  downwards,  exposing  the  dura.  The 
portion  of  the  zygomatic  process  which  has  been  temporarily  resected  is 
carried  down  with  this  flap  and  increases  the  space  very  considerably.  It 
is  best  to  ligate  the  middle  meningeal  artery  at  once,  because  this  can  be 
done  more  conveniently  before  the  tissues  have  been  disturbed  by  the 
remaining-  steps  of  the  operation.  The  dura  is  now  carefully  separated  to 
the  foramen  ovale,  then  it  is  elevated  between  the  foramen  ovale  and  the 
foramen  rotundum  by  means  of  a  blunt  instrument.  The  three  branches 
and  the  root  of  the  Gasserian  ganglion  are  then  elevated,  care  being  taken 
not  to  approach  the  inner  side  of  the  Gasserian  ganglion  until  the  remaining 
portion  of  the  isolation  has  been  completed,  because  of  the  danger  of  injur- 
ing the  cavernous  sinus  and  thus  clouding  the  field  of  operation  for  the 
remaining  steps. 

The  second  and  third  branches  of  the  nerve  are  then  severed  am' 
the  Gasserian  ganglion  grasped  by  means  of  forceps  and  forcibly  loosened 
from  its  attachment.  In  case  there  is  still  a  considerable  amount  of  oozing 
a  warm,  moist  gauze  tampon  is  applied  and  left  in  place  undisturbed  for  at 
least  five  minutes.  It  is  then  slowly  removed  and  the  clamp  upon  the  carotid 
artery  is  slowly  loosened.  If  hemorrhage  occurs,  which  is  not  likely  unless 
the  middle  meningeal  artery  has  not  been  properly  ligated,  the  clamp  is 
again  tightened  carefully  until  the  flow  ceases  and  the  bleeding  points  are 
caught  and  ligated  with  fine  cat-gut,  if  this  is  possible,  otherwise  a  small 
iodoform  gauze  tampon  is  applied  and  held  in  place.  This,  however,  is  not 
often  necessary.  The  flap  is  then  replaced  and  the  skin  sutured,  care  being 
taken  to  pass  the  stitches  entirely  through  the  scalp  in  order  to  stop  bleed- 
ing from  the  scalp  wound  after  the  clamp  is  loosened.  Xo  attention  is 
paid  to  the  resected  zygomatic  process  unless  it  refuses  to  stay  approxi- 
mately in  its  right  position.  In  that  case  it  is  held  in  place  by  a  few  cat-gut 
sutures.  During  this  portion  of  the  operation  the  patient  is  permitted  to 
awaken  and  is  placed  in  the  vertical  position.  The  dressings  are  applied 
and  carefully  bandaged.  It  is  well  to  place  a  light  gauze  pad  over  each 
eye  and  to  apply  a  loose  bandage  over  this,  because  in  this  way  the  eye 
on  the  normal  side  will  remain  quiet  and  with  its  fellow  will  remain  undis- 
turbed. If  the  normal  eye  is  left  open  the  other  eye  will  be  compelled  to 
move  with  every  motion  of  the  normal  one,  and  consequently  it  will  be 
likely  to  be  disturbed  unnecessarily. 

This  operation  in  the  hands  of  all  operators  together  has  given  a  con- 
siderable mortality,  probably  exceeding  twenty  per  cent,  while  in  the  hands 
of  a  few  surgeons  who  have  carefully  developed  technique  the  mortality 
has  been  exceedingly  small. 

AYe  have  found  it  advantageous  to  administer  one-fourth  of  a  grain  of 
morphia  hypodermically  to  these  patients  half  an  hour  before  beginning 
the  administration  of  the  anesthetic,  then  to  anesthetize  with  ether  by  the 
drop  method  until  the  patient  is  very  thoroughly  unconscious  and  then  to 
stop  the  further  administration  of  the  anesthetic  just  before  beginning  the 


122  SURGERY  OF  THE  HEAD 

operation,  the  patient's  head  being  elevated  by  placing  the  table  in  the 
inverted  Trendelenburg  position.  The  anemia  of  the  brain  caused  by  this 
procedure  serves  to  keep  the  patient  unconscious  until  the  operation  has 
been  completed  and  reduces  the  amount  of  bleeding  to  a  marked  extent. 

It  may  be  well  to  caution  the  surgeon  against  the  careless  use  of  the 
retractor  in  lifting  the  cerebrum.  A  spatula-shaped  retractor  is  usually  held 
by  an  assistant  for  this  purpose  and  unless  he  has  been  very  carefully 
cautioned  there  is  danger  of  his  traumatizing  the  brain  tissue  during  the 
excitement  of  the  operation.  This  part  of  the  work  should  be  given  to 
a  thoroughly  competent  assistant. 

Shock  due  to  avoidable  traumatism  is  undoubtedly  the  cause  of  more 
deaths  during  or  following  this  operation  than  any  other  one  condition, 
which  accounts  for  the  difference  in  mortality  at  the  hands  of  otherwise 
equally  competent  surgeons. 

RESECTION    OF    PORTIONS    OF  THE   FACIAL   NERVE  FOR   THE 
RELIEF  OF  NEURALGIA. 

During  the  early  portion  of  an  attack  of  trifacial  neuralgia  usually 
only  one  of  the  principal  branches  is  involved.  The  most  common  one,  in 
our  experience,  has  been  the  submaxillary  branch. 

Internal  Treatment  and  Dietary. 

In  all  cases  of  trifacial  neuralgia,  without  regard  to  the  portion  of  the 
nerve  involved,  it  is  wise  always  to  subject  the  patient  first  to  carefully 
directed  internal  treatment.  In  a  considerable  proportion  of  these  cases 
the  affection  seems  to  be  due  to  an  auto-toxemia  from  the  alimentary  tract. 
In  these  cases  the  daily  use  of  from  two  to  four  ounces  of  castor  oil,  given 
in  the  foam  of  beer,  will  result  in  a  permanent  cure  in  at  least  one-half  of 
all  instances.  At  first  the  oil  will  act  as  a  violent  cathartic,  but  this  prop- 
erty soon  disappears,  and  after  a  few  weeks  the  patient  may  continue  to 
take  this  amount  of  castor  oil  daily  without  any  disturbance  of  the  bowels. 

In  the  meantime  these  patients  should  be  cautioned  against  the  use 
of  food  which  is  likely  to  cause  undue  fermentation.  Sugar  should  be 
prohibited  entirely.  Starchy  foods  should  be  limited,  and  acids  should  be 
used  very  sparingly.  In  case  this  and  other  forms  of  treatment  fail  to 
give  relief  to  the  patient  the  excision  of  a  portion  of  the  affected  nerve 
is  indicated.  During  the  past  few  years  a  number  of  surgeons  have  advised 
the  excision  of  the  Gasserian  ganglion  for  the  relief  of  all  facial  neuralgias 
without  regard  to  the  branch  involved.  This  seems,  however,  scarcely 
justifiable,  because  in  many  cases  in  which  only  a  portion  of  the  affected 
branch  has  been  excised  the  patient  has  recovered  completely  and  perma- 
nently ;  and  if  a  complete  recovery  does  not  occur,  it  is  still  possible  to 
perform  a  radical  operation. 

Injection  of  Alcohol. 

During  the  past  few  years  we  have  obtained  excellent  results  in  many 
cases  by  injecting  i  per  cent  cocain  in  85  per  cent  alcohol  directly  into  the 
nerve  sheath,  or  as  near  the  nerve  as  possible.  This  should  be  repeated 
once  a  week  until  the  pain  ceases  to  return.  Sometimes  one  injection 
will  suffice  but  more  frequently  it  is  necessary  to  repeat  this  several  times. 
It  may  be  necessary  to  inject  as  often  as  five  or  even  ten  times.  In  cases 


SURGERY   OF   THE  HEAD  123 

which  are  relieved  by  this  method  one  can  usually  count  on  freedom  from 
pain  for  at  least  one  year  when  the  treatment  may  be  repeated  sometimes 
with  equally  satisfactory  results. 

In  the  meantime  the  patient  should  be  under  strict  supervision  regard- 
ing- the  state  of  his  general  health.  His  diet  and  hygiene  should  be  care- 
fully controlled.  The  food  should  be  consistently  chosen,  thoroughly  masti- 
cated, and  absorption  of  products  of  decomposition  from  the  contents  of 
the  alimentary  canal  should  be  prevented.  The  urine  should  be  examined 
at  regular  intervals,  especially  for  the  presence  of  indican. 

The  condition  of  the  patient's  teeth  should  be  made  as  nearly  perfect 
as  possible,  and  all  other  influences  affecting  the  patient's  general  health 
should  be  carefully  controlled. 

Technique. 

In  order  to  succeed  it  is  well  to  have  a  human  skull  at  hand  at  the 
time  of  the  operation,  inasmuch  as  this  gives  the  operator  a  better  idea  of 
distance  and  direction  than  he  can  have  otherwise. 

It  is  also  advisable  to  inject  methyl  blue  experimentally  in  the  cadaver 
in  order  to  gain  accuracy  in  actually  reaching  the  nerve. 

Especial  needles  10  cm.  long,  i  mm.  or  il/2  mm.  in  diameter,  con- 
taining a  stylet,  can  be  obtained  from  the  instrument  makers  to  be  used 
in  this  operation,  but  different  surgeons  prefer  needles  of  different  thick- 
ness and  style,  the  important  point  being  to  secure  a  needle  that  will  pene- 
trate the  deep  tissues  in  the  exact  direction  intended  by  the  operator.  If  the 
injection  fails  to  give  relief  and  if  the  area  supplied  by  the  branch  injected 
is  not  analgesic  after  the  mixture  has  been  forced  into  the  tissues,  it  is 
certain  the  nerve  has  not  been  reached.  In  this  event  it  is  best  to  force 
the  needle  in  a  little  farther  and  to  inject  2  cc.  more  of  the  fluid.  If  this 
again  fails  the  needle  should  be  withdrawn  slightly  and  more  of  the  fluid 
should  be  injected  at  various  points.  If  this,  in  turn,  is  ineffectual  it  is 
best  to  withdraw  the  needle  and  to  bear  in  mind  the  direction  of  its  employ- 
ment and  then  to  repeat  the  injection  in  a  slightly  different  direction  after 
a  few  days.  It  is  rot  wise  to  risk  tearing  the  tissues  by  pushing  the  needle 
in  different  directions  at  one  sitting. 

Injection  of  the  Inferior  Branch  of  the  FiftJi  Xcrrc.  The  needle  is 
inserted  at  the  lower  border  of  the  zygoma,  one  inch  in  front  of  its  descend- 
ing root,  which  is  near  the  anterior  long  border  of  the  external  auditory 
meatus. 

The  needle  is  directed  a  little  backward  and  slightly  upward,  so  as 
to  hug  the  base  of  the  skull,  and  it  should  reach  the  nerve  at  its  exit  from 
the  skull  at  a  depth  of  4  cm. 

Tlic  Middle  Branch.  Draw  a  line  from  the  posterior  border  of  the 
ascending  process  of  the  malar  bone  to  the  lower  border  of  the  zygoma. 
Insert  the  needle  .5  cm.  posterior  to  this  point,  directed  so  that  it  would 
reach  the  foramen  rotundum  in  the  skull  you  have  for  comparison.  The 
nerve  is  reached  at  a  depth  of  5  cm. 

The  Supraorbital  Branch.  Inject  from  the  supraorbital  notch  or  fora- 
men. 

Osmic  Acid  Injections. 

Thi^  method  has  been  almost  entirely  discarded  since  the  introduction 
of  the  injection  of  alcohol.  It  differed  from  the  latter  in  the  fact  that  the 


124  SURGERY  OF  THE  HEAD 

diseased  nerve  was  laid  bare  at  the  most  available  point  and  a  few  drops 
of  osmic  acid  injected  directly  into  the  nerve.  The  results  were  no  better 
than  those  now  secured  from  the  injection  of  alcohol,  and  no  more  per- 
manent, hence  the  latter  method  must  be  preferred  because  of  its  ease  and 
safety  of  application. 

RESECTION  OF  THE  INFERIOR  DENTAL  AND  LINGUAL  NERVES. 

In  our  practice  these  two  branches  have  always  suffered  simultaneously, 
so  that  we  have  never  been  forced  to  operate  only  upon  one  or  the  other 
singly. 

Both  of  these  nerves  may  be  approached  conveniently  through  an  open- 
ing in  the  lower  jaw.  An  incision  is  made  along  the  lower  border  of  the 
jaw,  beginning  at  a  point  a  little  behind  the  angle  and  extending  forward  an 
inch  and  a  half.  This  incision  is  carried  down  to  the  bone.  The  periosteum, 
together  with  the  attachment  of  the  masseter  muscle,  is  then  pushed  up- 
wards by  means  of  a  chisel  and  an  opening  one-fourth  of  an  inch  in  diame- 
ter is  made  exactly  in  the  middle  of  the  ascending  ramus  of  the  jaw  by 
means  of  a  small  trephine  or  a  gouge.  This  will  expose  the  inferior  dental 
nerve.  The  nerve  is  picked  up  with  forceps  and  drawn  out  through  this 
opening.  Then  a  pair  of  hemostatic  forceps  is  placed  upon  the  nerve  and 
gentle  traction  made  forwards  and  downwards  to  loosen  it  as  much  as 
possible.  A  second  incision  is  then  made  directly  opposite  the  mental 
foramen.  The  mental  nerve  which  issues  from  this  foramen  is  readily 
found.  It  is  picked  up  on  an  elevator  and  severed.  The  portion  between 
the  mental  foramen  and  the  trephine  opening  is  then  drawn  out  of  this 
opening.  Traction  is  then  made  upon  this  portion  of  the  nerve  and  as  much 
as  can  be  drawn  out  of  the  foramen  is  cut  off.  In  such  manner  the  entire 
portion  of  the  nerve  within  the  canal  in  the  lower  jaw  is  removed.  A 
small,  blunt  hook  is  then  inserted  through  the  foramen  and  passed  around 
the  lingual  nerve,  which  is  drawn  out  through  the  trephine  opening,  caught 
with  hemostatic  forceps,  and  as  much  as  can  be  drawn  out  by  pulling  up- 
wards and  downwards  repeatedly,  is  withdrawn  through  the  trephine  open- 
ing. It  is  then  cut  loose  on  the  distal  side  and  then  the  nerve  is  again 
caught  with  a  pair  of  artery  forceps,  which  are  twisted  slowly,  so  that  the 
nerve  is  rolled  upon  the  forceps  like  the  rope  upon  a  windlass.  In  this 
way  a  considerable  portion  of  the  nerve  can  usually  be  drawn  out. 

We  believe  that  in  our  early  cases  we  failed  to  remove  a  sufficient  por- 
tion of  each  nerve,  and  consequently  experienced  recurrence  in  some  of  these 
cases,  much  more  frequently  than  we  have  since  performing  this  more  thor- 
ough operation. 

RESECTION   OF  THE  INFRAORBITAL   NERVE. 

The  infraorbital  nerve  is  the  most  common  seat  of  trifacial  neuralgia, 
according  to  statistics  found  in  literature,  but  in  my  own  experience  it  has 
been  less  frequent  than  in  the  inferior  maxillary  branch. 

The  simplest  method  of  approaching  this  nerve  consists  in  making  an 
incision  along  the  lower  edge  of  the  orbit  three-fourths  of  an  inch  in  length, 
directly  over  the  infraorbital  foramen,  which  can  readily  be  located  by 
making  pressure  along  this  margin  of  the  orbit  and  determining  the  most 
painful  point.  Care  should  be  taken  to  make  this  incision  slowly,  in  order 


SURGERY   OF   THE  HEAD  125 

not  to  sever  the  infraorbital  artery  at  the  point  at  which  it  issues  from  the 
foramen,  as  this  would  cloud  the  field  of  dissection  with  blood.  The  three 
branches — the  supramaxillary,  sphenopalatine  and  infraorbital  nerves — 
usually  do  not  separate  before  issuing-  from  this  foramen,  but  caution  should 
be  observed  in  making  the  dissection  not  to  overlook  one  or  the  other  of 
these  branches  in  case  division  has  taken  place  before  exit  from  this  fora- 
men. 

When  the  nerve  has  been  laid  bare  it  should  be  picked  up  on  a  dissector. 
(And  we  would  state  here  that  the  most  convenient  instrument  for  dissecting 
out  nerves  which  we  have  encountered  is  the  old-fashioned  dental  excavator, 
which  is  fine  enough  to  serve  properly  and  still  contains  sufficient  strength 
to  be  useful.)  If  the  foramen  is  complete  its  upper  portion  is  chiseled  away, 
transforming  it  into  a  groove.  The  nerve  is  then  grasped  with  a  pair  of 
hemostatic  forceps  and  drawn  upward,  and  its  branches  are  followed  with 
a  dissector  and  successively  cut  away  at  a  distance  of  about  three-fourths 
of  an  inch  from  the  foramen.  Careful  traction,  which  is  frequently  re- 
peated, is  then  made  upon  the  nerve  with  the  forceps.  In  this  manner 
more  and  more  of  the  nerve  can  be  withdrawn. 

If  the  neuralgia  has  been  severe  it  is  well  to  chisel  away  the  upper  wall 
of  the  canal  with  a  blunt  raspatory  after  loosening  the  periosteum  overlying 
it.  A  narrow  retractor  is  then  inserted  underneath  the  periosteum  and 
while  traction  is  made  upon  the  nerve  a  narrow  pair  of  scissors  is  inserted 
and  the  nerve  is  cut  off  a  considerable  distance  from  the  infraorbital  margin. 

EXCISION    OF   THE    SUPRAORBITAL    NERVE. 

The  operation  which  has  just  been  described  is  also  performed  for  the 
relief  of  supraorbital  neuralgia,  with  the  exception  of  making  an  incision 
along  the  supraorbital  margin  after  shaving  away  the  eyebrow.  If  the 
incision  is  made  directly  through  the  middle  of  the  eyebrow,  and  parallel 
to  it.  it  leaves  no  deformity. 

These  three  operations  are  relatively  simple  and  safe.  They  give  rise 
to  no  deformity,  and  unless  the  antrum  of  Highmore  is  opened  in  chiseling 
open  the  infraorbital  canal  the  wounds  all  heal  rapidly  and  perfectly.  In 
case  any  one  of  these  procedures  has  been  performed  and  there  is  a  recur- 
rence of  the  neuralgia  the  undertaking  may  be  repeated  and  a  second  attempt 
may  result  more  favorably.  If,  however,  a  radical  cure  of  the  condition  is 
desired,  then  it  is  best  to  excise  the  Gasserian  ganglion. 

HARE-LIP. 

Best  Time  for  Operating  and  Preparation. 

In  uncomplicated  cases  of  hare-lip  the  sooner  the  operation  is  per- 
formed, the  better  it  is  for  the  infant.  This  should  be  done  some  time  dur- 
ing the  first  ten  days.  In  cases  associated  with  cleft  palate,  especially  if  this 
be  complete,  it  is  better  to  follow  the  method  devised  by  Brown,  which 
consists  of  placing  a  strip  of  zinc  oxide  adhesive  plaster  across  the  lip  fissure, 
making  it  about  the  width  of  the  upper  lip  and  extending  sufficiently  across 
the  cheek  from  each  side  to  give  firm  resistance  when  tightly  drawn.  The 
strap  is  reapplied  daily  until  the  operation  is  performed. 

The  advantages  of  this  preliminary  treatment  are  that  it  not  only  pre- 


126  SURGERY   OF   THE   HEAD 

vents  an  increase  of  deformity  and  further  distortion  of  the  face  by  un- 
natural muscular  action,  but  it  has  a  tendency  to  correct  the  deformity,  as  in 
crying  and  laughing  the  principal  force  of  muscular  action  is  applied  to  the 
most  prominent  anterior  portion  of  the  maxillary  bones,  which  in  double 
hare-lip  and  cleft  palate  is  the  mandibular  process. 

It  also  has  a  decided  effect  in  the  single  cases,  as  in  all  of  them  the 
maxillary  is  more  prominent  on  one  side  than  on  the  other,  and  the  strap 
has  the  tendency  to  depress  the  more  prominent  side  and  to  bring  the 
shorter  side  forward.  Furthermore,  the  infant  becomes  accustomed  to  take 
nourishment  with  the  lip  in  a  condition  similar  to  that  after  operation  and 
to  breathe  through  the  reduced  air  space.  After  the  daily  application  of 
the  adhesive  straps  for  a  period  of  ten  days  or  two  weeks,  the  above  ad- 
vantages will  have  been  gained  and  the  defect  in  the  lip  should  be  closed. 

Technique. 

The  steps  of  the  operation  should  be  planned  so  that  after  closure  of 
the  fissure  there  will  be  practically  no  scar  and  as  little  deformity  of  the  lip 
as  possible.  The  freeing  of  the  lip  from  the  check  is  one  of  the  most  im- 
portant parts  of  the  operation,  for  unless  this  is  thoroughly  done  it  will 
be  impossible  to  bring  the  edges  of  the  lip  together  without  tension,  which 
is  apt  to  result  in  a  failure  of  union,  or  in  the  production  of  scars  caused 
from  cutting  of  the  tissues  by  the  stitches. 

After  the  lip  has  been  thoroughly  loosened  the  edges  of  the  cleft  in  the 
lip  must  be  prepared  for  suturing.  This  is  accomplished  by  using  a  very 
sharp,  thin-bladed  scalpel,  with  which  a  thin  strip  of  tissue  is  excised  from 
the  border  of  the  lip  on  each  side  of  the  fissure.  The  dissection  is  com- 
menced at  the  upper  border  of  the  lip  and  carried  downwards,  removing 
a  very  thin  layer  of  tissue.  The  mucous  membrane  from  the  lower  one-hal; 
centimeter  of  the  lip  is  not  excised,  but  is  left  as  a  wedge-shaped  projection 
at  each  corner  of  the  lip.  \Yhen  the  lip  is  sutured  the^e  two  wedge-shaped 
corners  are  brought  together  and  form  a  slight  projection  downwards, 
which  will  prevent  the  formation  of  a  notch  as  the  scar  contracts.  This 
aluo  helps  to  broaden  the  lip. 

If  the  lip  is  too  narrow,  it  may  be  broadened  by  making  a  curved  in- 
cision in  excising  the  mucou^  membrane,  having  the  convexity  of  the  incision 
toward  the  cheek  on  each  side,  thus  removing  only  a  thin  strip  of  mucous 
membrane  at  the  upper  and  lower  corners,  and  a  strip  about  one-half  centi- 
meter wide  from  the  center  of  the  lip.  As  the  two  concave  surfaces  arc 
brought  together  it  will  broaden  the  lip.  In  closing  the  lip  the  sutures 
should  be  placed  with  great  care  and  without  tension.  Two  tension  sutures 
of  .silkworm  gut  threaded  in  n  fine  needle  should  be  placed  first.  The. 
needle  enters  the  skin  about  one  centimeter  from  the  edge  and  is  carried 
in  an  oblique  direction  and  emerges  from  the  lip  just  at  the  edge  of  the 
mucous  membrane  or  the  posterior  surface  of  the  lip.  It  is  then  passed  into 
the  edge  of  lip  on  opposite  side,  entering  at  the  edge  of  the  mucous  mem- 
brane and  emerging  at  a  point  one  centimeter  from  the  border  on  the  skin 
surface.  These  two  sutures  are  left  untied  until  the  adaptation  sutures  have 
been  placed. 

The  mucous  membrane  of  the  lip  is  no\v  sutured  with  line  catgut 
throughout,  and  the  edges  of  the  skin  coaptated  bv  placing  a  fe\v  horse-hair 
stitches.  The  tension  sutures  are  then  tied,  but  care  should  be  given  not  to 
tie  them  too  tightly.  Adhesive  strips  should  now  be  applied,  so  as  to  take 


SURGERY   OF   THE  HEAD  12? 

all  the  tension  away  from  the  stitches.  The  stitches  should  be  removed  at 
the  end  of  a  week,  but  the  adhesive  strips  should  remain  in  place  for  two 
or  three  weeks. 

DOUBLE  HARE-LIP. 

In  cases  in  which  the  prolabium  has  been  left,  it  is  usually  advisable  to 
depress  this  projection  somewhat,  and  then  utilize  it  as  a  central  island  in 
the  formation  of  the  new  lip.  The  mucous  membrane  should  be  dissected 
off  of  the  three  borders  of  the  prolabium,  and  from  the  two  borders  of  the 
lip.  An  incision  about  one-half  centimeter  long  should  be  made  in  each  lip 
a  little  below  its  center  and  at  right  angles  to  its  freshened  edge.  The 
upper  half  of  the  lip  is  now  sutured  to  the  lateral  borders  of  the  pro- 
labium, and  the  edges  of  the  '"land"  half  of  lip  are  sutured  to  each  other 
in  the  mid  line  and  above  to  the  lower  border  of  the  prolabium. 

CLEFT  PALATE. 

If  a  hare-lip  is  associated  with  a  cleft  palate,  the  lip  should  be  repaired 
immediately  or  some  time  during  the  first  three  weeks  of  life,  and  the  cleft 
in  the  palate  left  until  some  later  time. 

Differing  Opinion  as  to  Best  Time  of  Operating. 

Authorities  arc  evenly  divided  on  the  question  of  time  for  operating 
for  closure  of  the  palatine  cleft ;  many  of  them  recommend  that  the  palate 
be  closed  in  infancy,  and  this  done  before  closure  of  the  hare-lip.  The 
advocates  of  the  early  operation  advise  that  the  palate  should  be  closed 
during  the  first  three  months  after  birth;  that  there  is  less  shock  at  this  time 
of  life  because  the  child's  nervous  system  is  not  fully  developed;  that  there 
will  be  the  minimum  amount  of  deformity,  for  they  claim  that  all  of  the 
tissues,  both  bony  and  soft,  will  develop  more  naturally  after  the  cleft  is 
closed,  and  that  this  development  will  allow  a  normal  speech  to  follow  when 
the  child  reaches  a  speaking  age. 

The  question  of  mortality  in  these  infants  is  an  important  one.  There 
is  no  doubt  but  that  these  little  patients  are  better  able  to  stand  an  operation 
of  this  kind  at  the  age  of  eighteen  months,  than  they  are  during  the  first 
few  months  of  life.  Furthermore,  children  during  their  first  year  are  more 
subject  to  toxemias  than  older  ones  and  are  apt  to  develop  intestinal  troubles 
following  the  operation,  which  are  likely  to  add  to  the  mortality.  It  is  the 
author's  custom  to  close  onlv  the  fissure  in  the  alveolar  process  before  the 
age  of  eighteen  months  and  to  leave  the  remaining  portion  until  such  time 
as  the  child  makes  an  attempt  at  talking.  We  also  caution  the  parents  of  such 
children  against  encouraging  them  in  these  attempts,  because  our  results 
have  been  more  satisfactory  when  the  operation  was  performed  at  the  age 
of  eighteen  months  or  two  years  than  when  the  operative  repair  was 
attempted  in  very  young  children;  moreover,  the  mortality  in  children  at  this 
age  has  been  practically  nothing,  while  in  those  younger  it  has  been  consid- 
erable. In  older  children  it  is  difficult  to  secure  perfect  speech  unless  great 
pains  is  taken  in  giving  them  instruction. 

Effect  of  Training  Upon  Speech. 

The  following  observation,  however,  has  convinced  us  that  it  is  possi- 
ble to  get  these  children  to  speak  very  nearly  perfectly  if  a  sufficient  amount 


128  SURGERY  OF  THE  HEAD 

of  care  and  patience  is  employed.  If  children  should  have  learned  a  given 
language  before  the  operation  was  performed  and  have  later  learned  another 
language,  we  have  found  that  the  language  which  they  learned  later  was 
spoken  perfectly,  while  the  defects  noted  in  the  language  learned  before  the 
operation  were  likely  to  persist.  It  is  consequently  plain  that  if  these 
children  were  taught  to  relearn  their  language  that  with  care  they  could 
accomplish  a  great  deal.  This  we  have  found  to  be  true  in  practice  and  we 
would  consequently  advise  a  systematic  course  of  instruction  in  the  forma- 
tion of  those  sounds  in  the  utterance  of  which  the  soft  palate  is  involved. 
Some  especially  gifted  teachers  have  succeeded  in  producing  perfect  results 
whenever  the  child  has  possessed  a  sufficient  amount  of  intelligence  to  appre- 
ciate the  instruction  and  the  necessary  perseverance  to  carry  it  out. 

Technique. 

Certain  conditions  are  obviously  necessary  in  order  to  insure  success 
from  any  of  the  various  operations  which  have  been  devised  for  closure  of 
cleft  palate,  namely :  The  naso-pharynx  must  be  in  a  fairly  healthy  con- 
dition ;  the  operator  must  prepare  broad  edges  of  the  flaps  to  be  united ; 
the  flaps  must  be  sutured  carefully  and  without  tension ;  one  must  trau- 
matize the  tissues  as  little  as  possible ;  must  keep  the  parts  as  clean  as  possi- 
ble after  operation,  and  it  is  important  to  keep  the  parts  relatively  quiescent 
after  operation. 

The  success  of  this  operation  depends  largely  upon  the  thoroughness 
with  which  the  flaps  are  loosened,  and  if  the  surgeon  appreciates  the  fact  that 
his  operation  is  not  likely  to  succeed  so  long  as  there  is  any  tension  upon 
the  stitches  which  unite  the  edges  of  the  wound  in  operations  for  the  relief 
of  cleft  palate,  he  has  grasped  the  most  important  principle  in  this  operation. 
The  method  of  the  operation  will  vary  with  the  extent  of  the  cleft.  If  this 
is  only  through  the  soft  palate,  it  is  wise  to  split  the  edge  of  the  cleft 
throughout  its  entire  extent,  beginning  at  the  tip  of  the  uvula  on  one  side, 
extending  this  incision  around  the  entire  cleft  to  the  tip  of  the  uvula  on  the 
other  side.  This  produces  a  broad  surface  for  coaptation.  It  is  necessary 
to  make  use  of  an  exceedingly  sharp  scalpel  in  order  to  accomplish  this 
incision  satisfactorily.  After  this  has  been  accomplished,  a  method  must  be 
adopted  for  loosening  the  flaps  on  either  side  so  thoroughly  that  they  will 
come  together  without  the  slightest  tension.  This  can  be  brought  about  by 
making  two  lateral  incisions  along  the  outer  edge  of  the  palate  and  loosening 
the  soft  tissues  by  means  of  an  elevator,  or  a  small  chisel  may  be  applied 
to  the  alveolar  process  of  the  palate  bone  and  this  may  be  chiseled  off,  as 
shown  in  the  drawing. 

It  matters  little  how  large  an  incision  or  opening  is  made  upon  each 
side,  provided  the  flaps  can  be  sufficiently  freed  so  that  they  will  come 
together  without  injury.  The  lateral  incisions  will  invariably  heal  spon- 
taneously. 

Involvement  of  Hard  Palate. 

In  case  the  cleft  extends  into  the  hard  palate,  or  through  the  hard  palate, 
the  following  method  has  been  most  satisfactory  in  our  hands,  although  it 
is  more  troublesome  than  some  of  the  other  procedures  that  have  been 
found  equally  useful  by  other  surgeons.  The  incision  is  made  under  the 
alevolar  process  on  each  side.  A  broad,  thin  chisel  is  placed  in  this  incision 
and  the  horizontal  portion  of  the  palate  is  chiseled  away  so  that  there  is  a 


PLATE  II. 

^  PALATE  OPERATION. 

(a)  Shows  sutures  on  mucous  membrane  turned  into  nasal  cavity;  (b)  sutures  on 
flap  turned  into  the  cavity  of  the  mouth:  (c)  the  silkworm  gut  suture  which  holds 
together  the  bone  flaps;  (d)  flap  turned  into  the  nasal  cavity:  (e)  flap  turned  into 
cavity  of  mouth;  (f")  incision  through  hard  palate.  In  order  to  make  the  conditions 
clear  the  drawing  was  made  to  represent  only  the  lower  surface  of  the  upper  jaw 
with  the  hard  and  soft  palate. 


SURGERY  OF  THE  HEAD  13! 

perfectly  loose  flap  consisting  of  mucous  membrane  of  the  mouth,  the  bone 
of  the  palate  and  the  mucous  membrane  of  the  nasal  cavity  attached  only 
in  front  and  behind.  If  one  side  or  the  other  is  attached  to  the  vomer  this 
attachment  is  also  loosened.  If  this  flap  is  made  so  loose  on  each  side  that 
it  can  be  carried  over  to  the  flap  on  the  other  side  without  the  use  of  any 
force,  then  one  may  usually  count  on  a  successful  result. 

Hemorrhage. 

The  hemorrhage  in  this  operation  is  considerable,  but  it  can  readily  be 
controlled  by  means  of  a  tampon.  The  patient  is  in  the  Trendelenburg 
position,  with  the  head  projecting  beyond  the  table,  consequently  there  is 
no  danger  of  the  inspiration  of  blood.  After  these  flaps  have  been  made  the 
fissure  which  has  been  formed  under  the  alveolar  process  should  be  thor- 
oughly tamponed  with  iodoform  gauze  and  the  flaps  should  remain  undis- 
turbed for  one  or  two  weeks,  the  nose  and  mouth  being  frequently  irrigated 
each  day  with  normal  salt  solution.  At  the  end  of  this  time  the  flaps  are 
usually  very  vigorous  and  readily  heal  if  the  edges  are  freshened  in  the 
manner  we  have  just  described  in  connection  with  operation  for  cleft  of  the 
soft  palate. 
Sutures. 

The  most  satisfactory  suture  material  in  our  practice  has  been  horse- 
hair, because  it  is  slightly  elastic,  stretching  sufficiently  to  prevent  pressure 
necrosis.  Of  course,  it  is  necessary  not  to  tie  these  sutures  tightly  as  the 
same  elasticity  which  would  be  useful  if  these  sutures  are  tied  loosely  would 
then  become  harmful,  for  it  would  increase  the  amount  of  pressure  necrosis 
precisely  after  the  manner  of  an  elastic  ligature.  It  is  well  to  remember 
that  the  fewer  the  number  of  sutures  that  will  suffice  to  secure  perfect  apposi- 
tion the  greater  will  be  the  likelihood  of  union. 

In  order  to  hold  the  bony  portion  of  the  flaps  in  position  it  is  well  to 
pass  around  them  one  or  two  stitches  of  silkworm  gut,  which  should  be  tied 
just  tightly  enough  to  hold  the  tissues  together  and  not  tightly  enough  to 
cause  pressure  necrosis,  because  the  latter  condition  is  likely  to  result  in  a 
complete  severing  of  one  or  both  bony  flaps.  The  fissures  under  the  alveolar 
process  should  again  be  carefully  tamponed  with  iodoform  gauze.  If  the 
fissure  extends  through  the  alveolar  process  in  front,  this  should  be  mobilized 
on  either  side  some  distance  back  from  the  fissure  by  means  of  a  chisel 
applied  between  the  teeth,  and  then  the  edges  should  be  united  at  the  point  of 
fissure  by  means  of  a  catgut  suture. 

In  children  who  are  not  old  enough  to  remain  perfectly  quiet  during 
the  removal  of  the  stitches  it  is  best  to  administer  an  anesthetic  when  the 
stitches  are  removed,  for  fear  of  disturbing  the  line  of  union.  If  possible 
the  sutures  should  be  extracted  on  the  fifth  or  sixth  day,  as  if  they  are  left 
longer  they  sometime?  result  in  sloughing. 

Brown  Operation. 

Of  late  the  authors  have  been  doing  the  operation  as  devised  and  prac- 
tised by  Dr.  G.  Y.  T.  Brown,  and  with  excellent  results. 

The  operation  is  based  upon  the  fact  that  all  of  these  patients  have 
a  high  arch,  which  increases  the  diameter  of  the  mouth,  and  that  by  lower- 
ing the  roof  of  the  mouth  the  necessary  width  for  closing  the  fissure  is 
obtained.  The  technique  is  as  follows :  A  short  incision  is  made  along  the 
margin  of  the  alveolar  process,  extending  down  through  the  periosteum  of 


132  SURGERY  OF   THE  HEAD 

the  hard  palate.  A  small,  thin  chisel  is  then  inserted  down  to  the  bottom  of 
this  incision  and  the  tissues  of  the  roof  of  the  mouth,  together  with  the 
periosteum  of  the  palate  bone,  are  thoroughly  loosened  from  the  edge  of 
the  cleft  back  to  the  alveolar  process.  Both  sides  are  treated  in  the  same 
manner.  The  edges  of  the  palate  tissue  are  now  carefully  trimmed  off  in 
a  manner  so  as  to  secure  broad  surfaces  for  coaptation.  A  fine  silver  wire, 
with  a  silver  plate  about  one  centimeter  in  diameter  fastened  to  one  end, 
is  now  passed  through  the  flap  on  one  side  at  a  point  about  one  centi- 
meter from  its  inner  margin,  and  then  carried  across  and  brought  up 
through  the  opposite  flap  at  a  corresponding  point,  and  left  loose  until 
the  coaptation  sutures  have  been  placed.  The  edges  of  the  two  flaps  are 
now  very  carefully  united  by  horse-hair  or  fine  silk  stitches,  being  very 
cautious  not  to  draw  them  tight.  A  silver  plate  about  a  centimeter  in  diame- 
ter is  now  threaded  upon  the  free  end  of  the  silver  wire,  and  then  three 
or  four  drilled  shot  are  threaded  down  on  top  of  the  plate.  The  object  of 
using  several  of  the  shot  is  to  be  able  to  obtain  the  exact  tension  desired 
on  the  silver  stitch.  The  outermost  one  of  the  shot  is  now  crushed,  and 
then  the  tissues  tested  for  the  desired  tension.  If  the  tension  is  not  enough 
the  other  three  shot  are  pushed  down  a  little  and  the  next  are  crushed  on 
to  the  wire.  As  soon  as  the  desired  tension  is  secured  the  innermost  shot 
is  crushed  and  the  superfluous  wire  together  with  the  other  three  shot  are 
removed.  It  is  usually  necessary  to  make  one  or  two  lateral  incisions 


Plates  and  shot   threaded  on   silver  wire. 

through  the  flaps  along  the  alveolar  process  in  order  to  relieve  any  possi- 
ble tension  that  may  be  present.  The  stitches  should  be  left  in  place  about 
seven  to  ten  days,  cleansing  and  spraying  daily. 

FISTULAE  FOLLOWING  OPERATION. 

It  happens  occasionally  that  a  fistula  remains  in  some  portion  of  a 
wound  which  has  been  sutured.  This  may  be  due  to  the  cutting  of  a 
stitch  or  there  may  have  been  a  certain  amount  of  tension  which  prevented 
union,  or  there  may  have  been  a  slight  amount  of  infection.  If  these  fistula 
are  painted  every  day  with  tincture  of  cantharides  they  are  likely  to  unite 
very  rapidly.  If  they  fail  to  unite  after  this  treatment  has  been  tried  for 
several  weeks  it  is  best  to  leave  the  fistula  for  a  number  of  months  until 
the  surrounding  tissues  have  become  quite  normal  and  then  to  make  a 
longitudinal  incision  on  each  side  of  it  and  to  loosen  enough  of  the  soft 
tissue  to  permit  the  two  sides  to  come  together  in  mid-line  without  any 
tension.  These  incisions  should  be  long  enough  to  make  the  flaps  perfectly 
free.  Then  the  fistula  is  freshened  and  united  by  means  of  a  stitch.  Occa- 
sionally it  seems  better  to  make  a  horseshoe-shaped  incision  around  one  or 
the  other  end  of  the  fistula  and  thus  to  loosen  a  one-sided  flap  which  will 
heal  directly  over  the  opening. 

EMPYEMA  OF  THE  ANTRUM  OF  HIGHMORE. 

For  the  relief  of  an  einpyema  of  the  antrum  of  Highmore  the  most 


SURGERY  OF  THE  HEAD  133 

convenient  and  satisfactory  point  of  approach  is  through  the  canine  fossa. 
A  longitudinal  incision  is  made  parallel  with  the  alveolus  of  the  upper 
jaw,  two  centimeters  in  length,  at  the  point  at  which  the  mucous  membrane 
extends  from  the  jaw  to  the  cheek.  The  periosteum  is  elevated  for  a 
distance  of  two  centimeters  and  is  held  out  of  the  way  by  means  of  re- 
tractors. Then  an  opening  one  and  one-half  centimeters  in  diameter  is 
made  by  means  of  a  gouge,  the  ordinary  carpenter's  chisel  and  mallet  again 
being  used.  The  cavity  is  then  carefully  curetted,  first  with  a  large  and  then 
with  a  small  curette ;  then  it  is  repeatedly  sponged  out  with  a  dry  gauze 
sponge,  which  will  remove  any  granulations  or  remnants  of  polypi.  Then 
the  entire  cavity  is  sponged  with  a  piece  of  gauze  slightly  moistened  with 
ninety-five  per  cent  carbolic  acid,  or,  better  still,  the  entire  cavity  is  tam- 
poned full  of  a  strip  of  gauze  moistened  in  this  manner.  This  tamponing 
is  repeated  a  number  of  times,  so  that  all  the  lining  of  the  cavity  of  the 
antrum  has  been  kept  in  contact  with  the  strong  carbolic  acid  for  a  period 
of  about  five  minutes.  Then  it  is  tamponed  several  times  with  a  strip  of 
gauze  saturated  with  strong  commercial  alcohol  in  order  to  wash  away 
any  superfluous  carbolic  acid.  After  this  the  cavity  is  tamponed  with  iodo- 
form  gauze  saturated  with  tincture  of  benzoin.  This  may  be  left  in  place 
for  a  number  of  days,  the  antiseptic  qualities  of  benzoin  being  sufficient 
to  prevent  the  cavity  from  becoming  foul.  After  this  has  been  removed 
it  is  usually  sufficient  to  insert  a  small  self-retaining  rubber  cannula  through 
which  the  antrum  may  be  irrigated  daily  with  some  mild  antiseptic  fluid. 
If  the  infection  of  the  antrum  has  not  been  of  long  standing  it  is  not  neces- 
sary to  make  so  radical  an  operation,  the  simple  opening,  irrigation  and 
drainage  of  the  cavity  often  sufficing. 

In  old  cases  it  is  w7ell  to  remove  the  separating  bony  wall  into  the 
nose  for  permanent  drainage  and  for  the  purpose  of  obtaining  an  easily 
accessible  opening  through  which  the  cavity  may  be  cleansed. 

Beck's  Bismuth  Paste. 

Since  the  introduction  of  Beck's  bismuth  paste  we  have  had  excellent 
results  in  the  after-treatment  of  these  cases  by  tamponing  the  cavity  with 
gauze  filled  with  this  paste  once  in  two  or  three  clays,  and  later  by  inject- 
ing the  paste  through  the  artificial  opening  and  then  closing  this  opening 
with  a  small  gauze  tampon.  This  treatment  is  repeated  daily  at  first  and 
less  and  less  frequently  later  on. 

Mild  cases  will  recover  if  the  antrum  is  filled  in  the  same  manner 
with  Beck's  bismuth  paste  through  a  cannula  introduced  through  the  nose, 
without  making  an  artificial  opening  into  the  antrum,  the  nostril  being 
tamponed  with  gauze  after  filling-  the  antrum. 

Except  in  cases  of  very  long  standing  it  is  advisable  to  try  this  method 
first,  for  a  few  weeks,  instead  of  at  once  choosing  the  operative  treatment. 
In  case  the  antrum  contains  neither  polypi  nor  necrosed  bone  the  suppura- 
tion decreases  rapidly  and  then  the  injection  should  be  made  less  fre- 
quently. It  is  wise,  however,  to  inject  the  bismuth  paste  once  a  week  after 
the  condition  seems  normal. 

EMPYEMA  OF  THE  FRONTAL  SINUS. 

The  treatment  which  has  just  been  described  for  empyema  of  the 
antrum  of  Highmore  is  equally  applicable  to  the  above  condition. 

After  thoroughly  disinfecting  the  nose  a  cannula  is  carried  up  into  the 


134  SURGERY  OF  THE  HEAD 

affected  sinus  and  the  latter  is  filled  with  Beck's  bismuth  paste  under  very 
moderate  pressure,  the  paste  being  heated  to  110°  F.  It  is  important  to 
inject  the  fluid  slowly  and  to  continue  the  injection  for  several  minutes  in 
order  to  fill  every  portion  of  the  cavity.  In  case  it  is  not  possible  to  pass 
a  cannula  of  about  2  mm.  diameter  through  the  nose  into  the  frontal 
sinus  a  passage  should  be  made  with  a  fine  bone  curette,  or,  if  this  is  not 
possible,  with  a  fine  gouge.  This  can  be  done  under  local  anesthesia  with 
cocaine  or  general  anesthesia  with  ether  may  be  employed. 

After  the  sinus  has  been  filled  with  the  bismuth  paste  the  nasal  cavity 
is  tamponed  with  gauze  which  has  also  been  saturated  with  the  paste  which 
will  serve  to  keep  this  cavity  as  nearly  aseptic  as  possible. 

INFECTION  OF  ETHMOID  CELLS. 

In  many  cases  this  affection  precedes,  accompanies  or  follows  the 
condition  just  discussed.  The  treatment  in  these  cases  depends,  as  in  the 
two  previous  diseases,  upon  disinfection  and  drainage,  the  latter  in  most  in- 
stances accomplishing  the  former.  Recently  operations  upon  these  cells 
have  been  undertaken  in  many  cases  which  would  undoubtedly  have  re- 
covered perfectly  and  permanently  without  the  necessary  defect  following 
an  operation  had  the  patient's  general  state  of  health  been  more  carefully 
directed.  This  is  especially  true  regarding  habitual  errors  in  respiration  in 
many  of  these  patients.  Their  breathing  is  habitually  so  shallow  that  they 
never  either  fairly  fill  or  empty  their  lungs,  and  consequently  leave  the 
mucous  surfaces  constantly  congested.  By  instructing  them  to  inhale  to 
their  fullest  capacity  and  then  forcibly  blow  out  the  air  through  a  small 
glass  tube  until  their  lungs  are  as  nearly  empty  as  possible,  doing  this 
many  times  a  day,  these  surfaces  clear  up  rapidly  and  in  early  cases,  if 
this  practice  be  continued,  we  have  seen  many  who  have  remained  per- 
manently well,  so  far  as  their  ethmoid  cells  were  concerned,  while  their  gen- 
eral health  was  vastly  improved.  Of  course  the  diet  and  habits  of  work 
and  sleep,  as  well  as  the  ventilation  of  living  and  sleeping  rooms,  must  be 
regulated  at  the  same  time. 

Technique. 

Under  local  anesthesia  with  two  to  five  per  cent  cocaine  in- 
jected through  a  fine  long  needle,  it  is  possible  to  secure  satisfactory  drain- 
age by  curetting  away  the  infected  cells  with  a  strong,  fine,  sharp  curette, 
or  to  bite  them  away  with  strong  sharp  gnawing  forceps.  A  dry  tampon 
is  first  applied  and  left  in  place  for  at  least  five  minutes,  then  the  space  is 
tamponed  with  gauze  saturated  with  compound  tincture  of  iodine  and  then 
with  gauze  saturated  with  Beck's  bismuth  paste.  In  obstinate  cases  2  to  10 
per  cent  of  nitrate  of  silver  solution  may  be  used  on  the  tampon  or  10 
per  cent  solution  of  argyrol. 

It  is  important  to  bear  in  mind  the  relation  between  these  cells  and  the 
meninges  because  it  has  repeatedly  happened  that  an  inexperienced  operator 
has  caused  a  meningitis  by  carrying  his  manipulations  too  far. 

Frequently  the  infection  of  the  ethmoid  cells  is  due  to  an  infection 
caused  by  the  presence  of  nasal  polypi.  These  ma}-  produce  the  infection 
simply  from  an  extension  of  this  process,  or  the  natural  drainage  may  be 
interfered  with  owing  to  a  blocking  of  the  nasal  space  due  to  the  presence 
of  polypi. 


SURGERY  OF  THE  HEAD  135 

NASAL  POLYPI. 

Usually  patients  do  not  come  under  the  surgeon's  care  until  nasal 
polypi  have  attained  a  sufficient  size  to  cause  obstruction. 

Under  cocaine  anesthesia  the  pedicle  of  the  polypus  can  usually  be 
grasped  with  curved  polypus  forceps  passed  through  the  nares  under  the 
guidance  of  the  index  finger  introduced  through  the  mouth.  The  smaller 
polypi  must  be  removed  by  means  of  a  polypus  forceps  through  a  nasal 
speculum  with  illumination  from  a  head  mirror.  Freer's  instruments  seem 
most  convenient  for  this  purpose.  This  and  the  previous  operation  are  ac- 
companied by  severe  hemorrhages  which  may  necessitate  performing  the 
operation  in  several  stages,  with  intervals  of  several  days. 

It  is  possible  in  most  cases  to  do  the  operation  at  one  sitting  by  tam- 
poning the  surface  with  gauze  and  interrupting  the  operation  temporarily 
while  this  is  being  done,  but  the  effect  of  this  plan  is  often  not  borne  well 
by  the  patient. 

POST-NASAL  ADENOIDS. 

The  removal  of  these  structures  is  usually  accomplished  at  the  time 
of  some  other  operation,  like  excision  of  tonsils  or  of  tuberculous  lymph 
nodes  of  the  neck. 

The  patient  is  placed  in  Rose's  position  upon  his  back  with  the  head 
projecting  dependently  beyond  the  end  of  the  table  and  held  firmly  between 
the  hands  of  an  assistant.  Either  general  or  local  anesthesia  may  be  em- 
ployed. The  uvula  is  drawn  forward  with  the  index  finger  of  the  left  hand 
and  the  adenoids  on  the  posterior  wall  are  cut  away  quickly  by  means  of  a 
Gottstein  curette. 

A  small  ordinary  curette  is  then  introduced,  first  through  one  and 
then  through  the  other  nostril,  and  all  of  the  remaining  adenoids  are 
curetted  away  carefully  under  guidance  of  the  left  index  finger.  It  is  im- 
portant to  protect  the  opening  to  the  Eustachian  tube  with  the  end  of 
the  index  finger. 

The  entire  surface  is  then  very  vigorously  rubbed  with  the  index 
finger  covered  with  a  few  thicknesses  of  sterile  gauze. 

The  patient's  diet  and  hygiene  are  carefully  controlled  after  the  opra- 
tion  and  especial  stress  is  laid  upon  the  practice  of  breathing  exercises. 

CONTRACTED  NARES. 

Nares  which  have  been  contracted  because  of  former  injuries  to  the 
nose  should  be  treated  by  forcibly  loosening  the  displaced  bony  structures 
and  then  treating  the  condition  as  one  would  a  fractured  nose  primarily. 

FRACTURE  OF  NOSE. 

In  the  treatment  of  this  accident  two  results  must  be  constantly  borne 
in  mind:  i.  The  patient  must  be  able  to  breath  through  both  nostrils 
after  recovery.  2.  He  must  not  remain  unreasonably  deformed. 

The  first  object  may  be  accomplished  by  applying  suitable  perforated 
intranasal  splints  made  of  hard  rubber,  aluminum  or  silver.  The  latter  pur- 
pose is  fulfilled  by  carefully  regulating  the  support  to  the  external  surface 
of  the  nose  throughout  the  process  of  healing. 


136  SURGERY  OF  THE  HEAD 

DEFLECTED  SEPTUM. 

What  has  just  been  said  applies  with  equal  force  to  this  condition. 
By  grasping  the  deflected  septum  with  strong  forceps  and  thoroughly  frac- 
turing it  so  that  it  ceases  to  take  upon  itself  its  former  deformity,  and  then 
applying  the  same  intranasal  splints  for  a  month  excellent  cosmetic  and 
functional  results  may  be  looked  for. 

SADDLE-NOSE. 

If  this  condition  is  due  to  an  old  fracture  this  should  be  reproduced 
as  nearly  as  possible  and  then  the  case  should  be  treated  according  to  the 
method  already  described.  If  it  is  congenital  then  it  is  usually  best  to 
correct  the  deformity  by  the  use  of  paraffin  injections. 

Traumatism  is  the  most  common  cause  of  saddle-nose,  and  next  in 
frequency  comes  syphilis,  either  acquired  or  congenital.  It  may  also  result 
from  simple  abscess  of  the  septum.  Any  condition  causing  destruction  of 
the  nasal  septum,  may  result  in  this  deformity  as  that  removes  the  support 
of  the  nasal  bones  and  cartilages. 

Use  of  Paraffin. 

Several  methods  of  correcting  this  deformity  have  been  devised,  such 
as  inserting  plates  of  celluloid,  platinum  or  silver  underneath  the  skin,  as 
a  substitute  for  the  natural  bridge  of  the  nose,  but  none  of  them  is  as  simple 
or  effective  as  the  subcutaneous  injection  of  paraffin.  This  method  of 
treatment  is  very  simple  and  there  is  no  resulting  scar  from  its  use.  It 
has  a  further  advantage  in  that  it  causes  very  little  reaction  of  the  tissues 
and  does  not  necessarily  confine  a  patient  to  the  house,  thus  allowing  him 
to  immediately  resume  his  daily  pursuits. 

Although  the  treatment  is  very  simple,  still  there  are  some  dangers 
connected  with  the  use  of  the  paraffin.  The  chief  dangers  are  abscess  for- 
mation and  sloughing  of  the  tissues  from  infection,  also  sloughing  from 
pressure  necrosis  from  hyper-injection.  A  few  cases  of  embolism  have 
been  reported  immediately  following  injection  for  deformity  of  the  nose. 

Technique. 

If  the  patient  is  an  adult  and  is  not  particularly  nervous,  the 
paraffin  may  be  injected  without  the  use  of  a  general  anesthetic.  In  such 
it  is  well  to  administer  a  quarter  of  a  grain  of  morphine  hypodermatically 
half  an  hour  before  the  treatment  is  to  be  given.  The  majority  of 
patients  prefer  to  take  a  general  anesthetic,  the  after-effects  of  which  are 
very  slight,  because  the  patient  is  anesthetized  for  only  a  few  moments. 

It  is  very  important  that  absolute  asepsis  be  carried  out  during  the 
process  of  injection,  for  the  slightest  infection  is  apt  to  result  in  abscess 
formation  and  sloughing  of  the  tissues.  A  special  syringe  should  be  used 
so  that  the  paraffin  can  be  forced  out  through  the  needle  after  it  has 
hardened,  and  also  so  the  paraffin  may  be  injected  very  slowly.  The 
syringe  should  be  constructed  of  metal  and  fitted  with  a  thumb  screw  upon 
a  worm  on  the  piston-rod,  which  can  be  screwed  into  the  head  of  the 
syringe  after  it  has  been  filled  with  melted  paraffin.  A  good-sized  ring 
should  be  firmly  attached  to  the  distal  end  of  the  piston  rod  so  that  the 
piston  rod  may  be  turned  easily,  which  will  gradually  lower  the  piston 
and  force  the  paraffin  out  through  the  needle  in  the  shape  of  a  cylindrical 


SURGERY  OF  THE  HEAD  137 

thread.     The  syringe  as  devised  by  Harman  Smith  has  proved  very  sat- 
isfactory to  the  authors. 

The  paraffin  should  be  thoroughly  sterilized  and  then  is  maintained 
in  a  liquid  state  by  keeping  in  a  hot  water  bath  until  used.  The  paraffin 
is  now  poured  into  the  syringe,  and  allowed  to  solidify  before  injection. 
The  needle  on  the  syringe  should  be  about  two  inches  long  and  should 
be  inserted  from  above  downwards,  that  is,  toward  the  tip  of  the  nose,  so 
that  the  injection  will  be  made  toward  the  tip  of  nose  and  not  toward 
the  base.  In  the  three  cases  of  embolism  of  the  central  artery  of  the 
retina  immediately  following  injection  of  paraffin  for  correction  of  nasal 
deformity,  each  injection  was  directed  toward  the  root  of  the  nose  instead 
of  toward  the  tip.  The  skin  over  the  base  of  the  nose,  a  considerable  dis- 
tance above  the  depressed  portion,  should  be  grasped  between  the  thumb 
and  finger  of  the  left  hand,  and  the  needle  introduced  through  the  skin  at 
this  point,  then  the  needle  is  passed  downwards  along  underneath  the  skin 
to  a  point  near  the  lowest  part  of  the  depression.  An  assistant  now  grasps 
the  nose  at  its  base  just  above  the  depression  to  prevent  the  paraffin  from 
backing  up  above  the  depression.  The  piston  rod  of  the  syringe  is  now 
turned  slowly  and  as  the  paraffin  enters  the  tissue  it  is  gently  molded  into 
the  proper  shape.  Care  must  be  used  not  to  inject  too  much  paraffin. 
When  the  skin  over  the  area  of  injection  becomes  white  the  in- 
jection should  be  stopped.  If  the  depressed  area  has  not  been 
raised  sufficiently,  it  is  better  to  inject  a  second  or  third  time  than  to  cause 
too  much  tension  by  injection  of  a  large  amount  primarily.  Care  must 
also  be  used  to  have  the  paraffin  lodge  in  the  right  place,  otherwise  the 
deformity  may  be  increased.  After  the  injection  the  needle  puncture  is 
sealed  with  collodion  and  no  further  dressing  applied. 

FOREIGN   BODIES   IN   NOSE. 

Ordinarily  it  is  possible  to  remove  foreign  bodies  from  the  nasal 
cavity  without  difficulty  by  the  use  of  forceps,  blunt  curettes  or  wire  loops, 
but  if  they  have  been  in  position  long  enough  to  cause  edema,  necrosis  or 
suppuration  it  is  often  difficult  to  accomplish  their  removal. 

This  is  also  the  case  if  the  patient  has  had  foreign  bodies  forced  into 
the  nose  during  explosions  or  railway,  automobile  or  runaway  accidents. 

\Ye  have  removed  nails,  stones,  and  in  one  case  a  piece  of  wood  4xi-5x.5 
cm.  in  diameter  from  the  noses  of  such  patients. 

In  these  cases  general  anesthesia,  followed  by  a  careful  exploration  is 
necessary.  After  removal  of  the  foreign  body  the  space  should  be  carefully 
tamponed  to  prevent  infection  and  hemorrhage. 

EPISTAXIS. 

Following  the  various  operations  of  the  nasal  cavity,  and  sometimes 
independently,  patients  suffer  from  severe  hemorrhages  from  the  nose, 
which  may  be  almost  uncontrollable.  But  we  have  always  succeeded  in 
overcoming  the  hemorrhage,  even  in  the  most  desperate  cases,  by  taking  a 
piece  of  soft  gauze  twenty-four  cm.  long  and  twelve  cm.  wide,  and  fold- 
ing it  upon  itself  so  as  to  make  a  bundle  12  cm.  long  and  just  thick  enough 
to  occlude  the  posterior  nares.  The  width  must  vary  slightly  with  the 
size  of  the  patient  and  the  length  with  the  quality  of  the  gauze.  Two 


138  SURGERY  OF  THE  HEAD 

pieces  of  double  silk  are  tied  about  this  gauze  so  as  to  divide  it  into  three 
equal  portions.  A  small  soft-rubber  catheter  is  now  passed  through  each 
nostril  and  guided  out  through  the  mouth,  then  one  piece  of  the  silk  is  tied 
to  each  catheter  and  pulled  forward  through  each  nostril,  the  gauze  being 
guided  into  place  with  the  index  finger.  The  two  strands  of  the  double 
silk  strung  are  then  separated  and  a  pledget  of  cotton  sufficiently  large  to 
close  the  nostril  is  tied  into  this  string  on  each  side  the  gauze,  being  care- 
fully adjusted  in  the  posterior  nares  in  the  meantime  so  as  to  occlude  these 
completely. 

The  nostrils  will  become  filled  with  blood  and  this  will  form  a  plug 
which  will  supply  the  necessary  pressure  to  control  the  hemorrhage.  The 
strings  should  be  tied  over  the  anterior  plugs  in  such  a  manner  that  they 
can  be  readily  untied  in  two  or  three  days  for  the  removal  of  the  plugs, 
[f  the  bleeding  vessels  have  not  been  occluded  hemorrhage  will  recur  at  once 
or  after  a  short  time,  and  then  the  anterior  plugs  will  have  to  be  renewed. 

CHRONIC  RECURRENT  EPISTAXIS. 

This  condition  is  usually  due  to  anemia  and  should  be  treated  with 
internal  remedies,  diet  and  hygiene.  In  other  cases  it  is  due  to  an  erosion 
of  some  vessel  in  the  mucous  lining  of  the  nose.  In  such  event  the  bleeding 
surface  should  be  touched  with  the  electric  cautery  under  local  anesthesia. 

FRACTURES  OF  THE  LOWER  JAW. 

In  the  treatment  of  fractures  of  the  lower  jaw  the  fragments  may  be 
held  in  position  by  making  use  of  the  upper  jaw  as  a  splint,  by  forming  a 
splint  of  strong  wire  covered  with  fine  rubber  tubing  and  applying  it  along 
the  alveolar  process,  either  to  the  inside  or  outside  of  the  teeth,  or  upon 
both  sides,  and  holding  the  fragments  in  place  by  winding  wire  about  the 
splint  and  the  teeth.  A  grooved  metal  or  hard-rubber  splint  may  be  em- 
ployed to  envelope  the  teeth.  Gold  rims  may  be  placed  on  a  number  of 
teeth  and  these  may  be  held  in  position  by  means  of  screws.  A  horseshoe- 
shaped  splint  may  be  fitted  externally  to  the  lower  jaw  and  held  in  place 
by  means  of  bandages,  or  it  may  be  adjusted  mechanically  like  the  ingenious 
splint  introduced  by  Matas. 

Two  conditions  must  be  borne  in  mind  which  are  peculiar  to  fractures 
of  this  bone :  First,  the  proximity  to  the  cavity  of  the  mouth  which  always 
contains  pathogenic  micro-organisms ;  second,  the  fact  that  the  fracture 
must  be  so  dressed  that  feeding  of  the  patient  is  possible.  The  mouth  should 
be  frequently  irrigated  with  normal  salt  or  with  boric  acid  solution,  and  pro- 
vision should  be  made  for  passing-  a  tube  into  the  pharynx  through  which 
the  patient  may  receive  liquid  nourishment  at  regular  intervals.  Usually 
there  is  a  space  between  the  teeth  but  if  this  does  not  exist  a  tube  can  be 
carried  around  the  teeth  into  the  pharynx. 

In  a  large  proportoin  of  these  cases  there  is  a  communication  between 
the  fracture  and  the  mouth  cavity.  Fortunately  for  the  patient  infection 
of  these  compound  fractures  seems  less  harmful  than  in  other  bones. 

TUMORS   OF  THE  JAW. 

The  most  common  tumor  of  the  jaw  affects  the  alveolar  process.  It 
begins  as  a  hard,  fibrous  mass  near  the  root  of  a  tooth  and  progresses  into 


SURGERY  OF  THE  HEAD  139 

the  substance  of  the  jaw,  the  tooth  becoming  loosened,  and  may  develop  a 
growth  of  considerable  size.  Presently  it  advances  along  the  mucous  mem- 
brane of  the  mouth  and  later  it  may  extend  into  any  of  the  surrounding 
tissues.  During  the  early  part  of  its  development  this  tumor  is  composed 
of  only  fairly  developed  connective  tissue  cells.  As  it  advances  these  become 
more  and  more  embryonic  until  the  growth  has  the  appearance  micro- 
scopically of  a  spindle-celled  sarcoma.  If  it  is  partly  removed  its  growth 
seems  to  be  greatly  stimulated,  and  if  removed  incompletely  several  times 
it  will  progress  in  the  usual  course  pursued  by  a  sarcoma. 

Technique. 

To  make  room  one  or  two  teeth  should  be  extracted  beyond  each  end  of 
the  growth,  the  entire  alveolus  should  then  be  chiseled  away  deeply  and  the 
soft  tissues  covering  the  jaw  should  be  removed  together  with  the  bone. 
Then  the  entire  area  should  be  thoroughly  cauterized  either  with  a  Paquelin 
cautery  or  with  a  cautery-iron  of  considerable  size  which  has  been  heated 
to  white  heat  in  a  flame.  The  thorough  destruction  of  the  deep  tissues  by 
means  of  the  cautery  seems  to  be  the  important  part  of  this  operation.  If 
his  is  done  reasonably  early  these  growths  practically  never  recur. 

In  many  of  these  cases  that  have  come  early  we  have  been  able  to  cut 
away  the  growth,  together  with  the  underlying  periosteum,  with  a  sharp 
chisel  and  then  at  once  produce  a  deep  scar  with  the  actual  cautery  with- 
out being  compelled  to  remove  even  a  single  tooth.  This  should  always 
be  done  under  general  anesthesia  because  otherwise  one  is  likely  to  cauterize 
too  superficially.  In  the  presence  of  doubt  one  should,  however,  never  hesi- 
tate to  remove  one,  or  several,  or  even  all  of  the  teeth.  Thoroughness 
means  success  in  this  operation. 

DENTIGEROUS  CYSTS  OF  THE  JAW 

The  retention  of  the  embryonic  teeth  within  the  jaw  gives  rise  to  the 
formation  of  a  bone  cyst.  It  is  frequently  difficult  to  differentiate  this  from 
sarcoma  except  through  the  history,  although  the  cyst  wall  usually  yields 
under  pressure  with  the  finger  placed  upon  the  inner  side  of  the  jaw,  giv- 
ing rise  to  a  crackling  sensation.  The  patient  is  frequently  aware  of  the 
presence  of  a  swelling  for  months  or  years  before  the  physician  is  con- 
sulted. Were  he  suffering  from  a  sarcoma  there  would  be  secondary  in- 
volvement long  before  this  time.  During  the  early  part  of  the  development 
of  a  cyst  of  the  jaw,  however,  it  is  not  possible  to  make  a  positive  diagnosis. 
There  is  always  an  unerupted  tooth  as  the  cause  of  this  affection,  but  so 
few  patients  keep  an  accurate  record  regarding  the  number  of  teeth  they 
have  had  extracted  that  one  cannot  make  any  reliable  calculations  from 
the  number  of  teeth  that  are  left. 

Technique. 

The  jaw  should  be  chiseled  open  either  from  below,  an  incision 
being  made  through  the  skin  and  periosteum  and  the  latter  reflected,  or 
from  the  month,  one  or  two  teeth  being  extracted  to  make  room  for  the 
operation.  The  cavity  is  carefully  chiseled  out,  tamponed,  and  permitted 
to  heal  by  granulation.  Usually  some  remnant  of  the  embryonic  tooth  is 
found.  The  progress  is  good. 

Frequently  these  cases  come  under  the  care  of  the  surgeon  after  they 
have  been  operated,  showing  only  a  sinus  leading  down  to  the  denuded 


I4O  SURGERY  OF  THE  HEAD 

bone,  which  we  have  often  discovered  to  represent  the  lining  of  the  infected 
cyst,  but  more  frequently  we  have  found  a  portion  of  a  tooth  or  a  partly- 
developed  tooth  at  the  bottom  of  the  sinus. 

SARCOMA  OF  THE  LOWER  JAW. 

The  only  treatment  that  promises  relief  in  sarcoma  of  the  lower  jaw 
is  the  excision  of  the  entire  half  of  the  maxilla  involved.  This  is  accom- 
plished by  making  an  incision  along  the  lower  border  of  the  jaw  from  the 
angle  thereof  to  a  point  beyond  the  middle  line  of  the  chin.  The  soft  tissues 
are  carefully  separated,  the  mouth  opened,  a  tooth  is  extracted  opposite 
the  point  at  which  the  jaw  is  to  be  separated,  and  then  a  chain  saw  or  a 
wire  saw  is  carried  around  the  bone,  and  while  the  wound  in  the  skin  is  re- 
tracted in  order  to  prevent  its  injury,  the  bone  is  sawed  off.  The  end  of  the 
jaw  is  then  grasped  in  a  pair  of  lion- jawed  forceps  and  carried  out  through 
the  wound  in  the  skin.  If  the  tumor  is  located  near  the  angle  of  the  jaw 
it  is  best  to  remove  the  entire  half  of  the  maxilla,  making  an  ex-articulation. 
This  is  accomplished  by  successively  loosening  the  soft  tissues,  grasping  the 
bleeding  vessels  that  are  encountered,  and  forcing  the  jaw  outward,  dis- 
locating the  joint  and  then  cutting  away  the  capsule.  The  only  point  at 
which  one  encounters  any  difficulty  is  the  attachment  of  the  styloid  process, 
but  with  a  little  care  and  manipulation  this  can  be  loosened  readily. 

It  is  wise  to  grasp  the  facial  artery  and  vein  at  the  point  at  which  they 
cross  the  lower  jaw  before  cutting  these  vessels,  because  in  this  way  the 
wound  may  be  kept  practically  free  from  blood.  A  drain  is  inserted  in  the 
posterior  and  anterior  angles  of  the  wound.  The  mucous  membrane  is  first 
sutured  and  then  the  skin  is  sutured  up  to  the  point  of  drainage. 

In  case  any  of  the  surrounding  tissues  have  become  involved  these 
should  be  removed  freely,  but  it  is  doubtful  whether  much  benefit  can  come 
in  these  cases  from  an  operation  if  the  disease  has  advanced  to  the  point  of 
invasion  of  surrounding  tissues. 

CARCINOMA  OF  THE  LOWER  JAW. 

Carcinoma  of  the  epithelial  structures  of  the  mouth  frequently  invade 
the  lower  jaw.  Usually  cases  which  have  advanced  to  this  stage  are  prac- 
tically hopeless,  still  it  is  proper  to  attempt  the  cure  of  some  by  employing 
the  treatment  which  has  just  been  described  in  connection  with  sarcoma 
of  the  lower  jaw. 

ALVEOLAR   ABSCESS. 

This  affection  is  so  simple  that  it  seems  scarcely  necessary  to  describe 
its  treatment,  which  should  consist  in  thorough  disinfection  of  the  cavity 
of  the  mouth,  free  incision  of  the  abscess,  thorough  irrigation  of  the  mouth 
after  incision  at  intervals  of  one  hour  at  first  and  less  frequently  later. 
Should  the  incision  show  a  tendency  to  close  a  folded  piece  of  rubber  tissue 
may  be  inserted  to  keep  the  wound  open,  and  thus  facilitate  drainage  and 
healing  from  the  bottom. 

OSTEOMYELITIS   OF   THE   LOWER   JAW. 

Following  severe  infectious  diseases,  or  severe  infection  from  the  root 
of  a  tooth,  there  is  frequently  a  destruction  of  a  portion  or  the  entire  lower 
jaw,  due  to  osteomyelitis.  Occasionally  this  disease  also  follows  a  com- 


SURGERY  OF  THE  HEAD  14! 

pound  fracture  of  the  lower  jaw.     It  is  accompanied  by  severe  pain,  much 
edema,  a  high  temperature  and  frequently  by  severe  chills. 

Technique  in  Acute  Cases. 

When  seen  in  the  acute  stage  a  free  incision  should  be  made  through 
all  the  tissues,  including  the  periosteum  down  to  the  bone.  This  will  relieve 
the  tension  and  produce  drainage  by  directing  the  lymph  stream  away  from 
the  infected  area.  This  will  reduce  the  necrosis  of  bone  tissue  to  a  mini- 
mum. In  many  instances  almost  no  sequestration  will  follow,  as  the  bone 
seems  to  have  the  power  of  regenerating  without  destruction,  while  in  cases 
in  which  the  periosteum  has  not  been  incised  large  portions  of  the  bone 
will  be  exfoliated  in  the  form  of  sequestra. 

In  later  cases  in  which  the  jaw  bone  has  already  been  destroyed  by 
the  infection  it  is  a  grave  error  to  remove  the  dead  bone  at  once.  In  these 
the  periosteum  should  also  be  laid  open  and  the  dead  maxilla  should  be  left 
in  place  to  act  as  an  irritant  to  the  formation  of  an  involucrum,  and  also  to 
take  the  place  of  a  mold  over  which  the  involucrum  can  be  formed  without 
necessary  and  unsightly  deformity. 

This  treatment  will  be  followed  by  the  formation  of  a  nearly  perfect 
maxilla,  while  neglecting  to  incise  the  periosteum,  or  removing  the  dead 
bone  at  once,  will  be  equally  certain  to  produce  results  which  are  cos- 
metically  and  functionally  bad  in  proportion  to  the  extent  of  the  disease. 

Technique  in  Chronic  Cases. 

In  old,  neglected  cases  and  in  those  which  were  not  treated  sur- 
gically at  all  during  the  acute  stage,  or  treated  too  late,  or  in  which  the 
periosteum  had  been  properly  incised  during  the  acute  stage  and  in  which 
an  involucrum  has  properly  formed,  the  sequestrum  causes  continuous  dis- 
charge of  pus  through  one  or  more  fistula:.  In  all  these  the  sequestrum 
should  be  exposed. 

It  is  usually  necessary  to  cut  away  some  of  the  involucrum  here  or  there 
in  order  to  remove  all  of  the  necrosed  bone.  This  should  be  done  carefully 
in  order  not  to  fracture  the  involucrum.  The  space  should  be  temporarily 
tamponed  with  gauze  for  two  or  three  weeks ;  the  skin  should  be  carefully 
sutured  in  order  to  reduce  the  deformity  to  a  minimum.  After  the  gauze 
has  been  removed  it  is  well  to  fill  the  space  it  occupied  with  Beck's  bismuth 
paste,  consisting  of  one  part  of  subnitrate  of  bismuth  and  two  parts  of  yel- 
low vaselin.  It  is  important  not  to  inject  this  with  much  force,  and  the  in- 
jection should  be  repeated  once  or  twice  a  week  until  the  cavity  is  closed. 

PHOSPHORUS  POISONING. 

In  persons  working-  in  badly-ventilated  factories  wherein  phosphorus 
is  employed  in  various  manufactories,  a  necrosis  of  the  jaw  frequently 
occurs. 

The  treatment  must  consist  in  at  once  permanently  changing  the 
patient's  employment,  directing  his  diet  and  his  general  hygiene  and  in  treat- 
ing the  local  condition  the  same  as  acute  osteomyelitis. 

ANKYLOSIS  OF  JAW. 

In  complete  ankylosis  of  the  lower  iaw  the  same  operation  is  indicated 
as  in  ankylosis  of  other  joints,  which  is  described  in  another  chapter. 


142  SURGERY  OF  THE  HEAD 

In  partial  ankylosis  the  jaw  should  be  mobilized  under  ether  anesthesia 
and  cork  posts  should  the  be  placed  between  the  teeth  on  either  side,  with 
the  mouth  opened  to  the  greatest  possible  degree  in  any  given  case.  The 
patient  should  be  kept  fairly  free  from  pain  by  the  hypodermic  use  of  mor- 
phine for  at  least  a  week  while  the  mouth  is  being  held  open  in  this  man- 
ner. Then  the  posts  may  be  removed  and  somewhat  smaller  ones  put  in 
their  place  and  worn  regularly  during  the  night,  while  during  the  daytime 
the  patient  may  exercise  the  jaw.  It  may  be  necessary  to  repeat  the 
mobilization  under  anesthesia  several  times  at  intervals  of  several  weeks. 

The  treatment  should  be  continued  for  a  number  of  months. 

The  mouth  should  be  kept  covered  with  several  layers  of  gauze  while 
it  is  being  held  open  by  the  posts  in  order  to  prevent  harm  from  inspiration 
of  dust  or  cold  air. 

Even  after  the  patient  has  apparently  completely  recovered  it  is  well 
to  wear  the  posts  between  the  teeth  at  least  for  one  night  each  month  to 
prevent  recurrence. 

EXCISION  OF  THE  UPPER  JAW. 

The  method  introduced  by  Kocher  seems  most  satisfactory.  We  have 
practiced  it  in  many  cases.  It  can  be  done  most  easily  by  first  ligating  the 
common  carotid  artery,  temporarily,  or  by  ligating  the  external  carotid 
artery,  either  temporarily  or  permanently.  If  the  temporary  ligation  is  em- 
ployed this  is  removed  after  the  operation  upon  the  jaw  has  been  com- 
pleted, the  space  carefully  tamponed  with  gauze,  and  the  patient  placed  in 
the  sitting  posture. 

If  the  operation  is  performed  without  preliminary  ligation  the  patient 
should  have  his  head  elevated  throughout  the  operation  by  using  the  exag- 
gerated inverted  Trendelenburg  position.  A  few  times  we  have  performed 
the  operation  rapidly  in  elderly  persons,  in  whom  preliminary  ligation 
seemed  contra-indicated  because  of  the  presence  of  marked  arterio- 
sclerosis, with  the  patient  in  Rose's  position  with  the  head  dependent  be- 
yond the  end  of  the  table,  but  the  plan  of  operating  with  the  head  elevated 
seems  much  more  saisfactory. 

Technique. 

An  incision  is  made  in  a  vertical  direction  through  the  middle  of  the 
upper  lip,  it  then  follows  the  base  of  the  nose  up  to  the  edge  of  the  orbit, 
then  outwards  to  the  junction  of  the  malar  and  fourth  bones.  The  entire 
flap  is  reflected  outwards  and  then  the  jaw  is  cut  away  with  heavy  bone- 
cutting  forceps.  The  bleeding  is  controlled  by  pressure  with  gauze  pads. 

This  operation  is  indicated  only  for  the  removal  of  malignant  growths, 
hence  it  is  wise  to  apply  large  cautery  irons  heated  to  red-heat  to  all  of  the 
raw  surfaces.  This  will  destroy  any  remaining  portions  of  diseased  tissue 
and  will  definitely  stop  hemorrhage.  The  space  is  then  carefully  tamponed, 
preferably  with  formidine  gauze,  and  the  skin  ilap  is  carefully  sutured  in 
place  throughout. 

If  indicated  by  the  condition  of  the  malignant  growth  the  malar  bone 
may  be  removed  in  part  or  entirely.  If  its  orbital  plate  is  removed  it  is 
well  to  remove  the  eye  also. 

The  cosmetic  result  following  this  operation  is  relatively  very  satis- 
factory. 


SURGERY  OF  THE  HEAD  143 

EXCISION  OF  THE  PAROTID   GLAND. 

The  removal  of  a  portion  of  this  gland  is  most  frequently  indicated  in 
connection  with  the  removal  of  tuberculous  lymph  glands  of  the  neck.  Its 
total  removal  is  most  commonly  required  for  enchondroma.  It  is  important 
in  these  cases  to  make  a  perfectly  clean  dissection,  because  if  any  portion 
of  the  tumor  remains  it  is  likely  to  recur  in  the  form  of  sarcoma  which 
can  only  rarely  be  permanently  cured  by  a  secondary  operation.  On  the 
other  hand,  if  the  entire  gland,  together  with  its  capsule,  has  been 
enucleated  fairly  early  at  the  primary  operation  a  permanent  cure  may  be 
expected.  The  dangers  of  the  operation  are  unimportant  and  will  be  dis- 
cussed in  connection  with  the  operation  for  the  removal  of  tuberculous 
glands  of  the  neck. 

EXCISION  OF  THE  TONGUE. 

Carcinoma. 

Carcinoma  of  the  tongue  is  not  very  uncommon  and  fortunately  it  is 
frequently  amenable  to  surgical  treatment,  the  prognosis  being  favorable 
in  quite  a  considerable  proportion  of  cases.  If  the  portion  involved  is 
confined  to  the  anterior  half  of  the  tongue  its  removal  is  quite  simple.  The 
tongue  is  drawn  out  of  the  mouth,  is  transfixed  at  its  base  with  a  needle 
armed  with  a  strong  double  silk  suture ;  the  tongue  is  tied  in  halves,  con- 
siderable force  being  used  in  order  to  prevent  the  possibility  of  hemorrhage 
during  the  operation.  A  second  strong  silk  suture  is  passed  through  the 
tongue  just  above  the  insertion  of  the  first ;  with  this  the  tongue  is  drawn 
forward.  Then  the  diseased  portion  is  cut  away,  leaving  just  enough  be- 
yond the  silk  ligature  to  permit  the  suturing  of  the  two  halves  of  the 
tongue  in  the  median  line.  Upon  inspecting  this  surface  the  blood  vessels 
on  the  lower  surface  near  the  median  line  can  readily  be  discovered.  These 
are  caught  in  hemostatic  forceps  and  ligated  separately.  A  row  of  sutures 
is  then  applied,  bringing  the  two  halves  of  the  cut  edge  of  the  tongue  in 
accurate  apposition.  These  sutures  are  carefully  tied  and  then  the  silk 
sutures  are  cut.  The  second  silk  suture  which  was  applied  is  left  in  place 
for  twenty-four  or  forty-eight  hours  in  order  to  prevent  the  tongue  from 
falling  back  into  the  pharynx.  This  accident  happens  very  rarely,  but 
when  it  does  occur  it  is  very  troublesome  unless  some  provision  is  made 
for  holding  it  forward. 

Glandular  Invasion. 

The  submaxillary  lymphatic  glands  and  the  cervical  glands  in  front  of 
the  deep  jugular  vein  are  most  likely  to  be  involved  secondarily  in  this 
condition,  and  if  the  disease  is  at  all  advanced  it  is  wise  to  make  an  incision 
on  each  side  and  remove  these  glands,  even  though  it  may  not  be  possible 
to  palpate  them  through  the  skin.  If  the  disease  extends  to  the  posterior 
portion  of  the  tongue,  either  on  one  or  both  sides,  it  is  best  to  make  a 
temporary  ligation  of  the  external  carotid  artery  before  beginning  the  opera- 
tion. This  may  be  accomplished  most  readily  by  laying  bare  the  artery  at  its 
origin  on  each  side  and  applying  a  pair  of  clamps  which  have  been  especially 
constructed  for  this  purpose.  These  clamps  should  not  be  sufficiently 
strong  to  cause  any  injury  to  the  vessel,  but  just  strong  enough  to  prevent 
the  passage  of  blood  through  it.  The  jaws  of  the  instrument  should  be  cov- 
ered with  drainage  tubing  to  prevent  the  crushing  of  the  vessel  walls.  The 
operation  is  thus  rendered  practically  bloodless  and  can  be  accomplished 


144  SURGERY  OF  THE  HEAD 

with  great  thoroughness.  The  larger  vessels  should  be  caught  in  hemostatic 
forceps  and  ligated  separately  and  then  the  stump  which  is  left  should  be 
carefully  closed  by  means  of  a  sufficient  number  of  sutures  to  prevent  ooz- 
ing. After  the  entire  surface  has  been  carefully  covered  the  forceps  are 
loosened  first  on  one  side  and  then  on  the  other.  In  case  hemorrhage  occurs 
they  can  be  compressed  again  and  the  bleeding  controlled  by  the  further 
application  of  sutures. 

With  this  location  of  the  growth  there  is  still  greater  likelihood  of 
invasion  of  the  cervical  and  the  submaxillary  lymphatic  glands,  and  in  such 
instances  their  removal  is  always  indicated,  although  it  may  not  be  possible 
to  palpate  them  through  the  skin.  In  case  the  floor  of  the  mouth  is  in- 
volved together  with  the  tongue,  the  same  preliminary  compression  of  the 
external  carotid  should  be  made,  but  in  order  to  make  a  complete  removal 
of  the  tissues  it  is  wise  to  split  the  lip  and  the  lower  jaw  through  the  mid- 
dle down  to  a  point  just  above  the  thyroid  cartilage,  to  insert  retractors  in 
each  segment  of  the  jaw,  and  to  open  the  entire  space  by  careful  continuous 
dissection.  In  this  way  the  entire  floor  of  the  mouth  and  the  base  of  the 
tongue  may  be  perfectly  exposed.  The  larger  blood  vessels  are  caught  and 
ligated  successively. 

The  excision  of  the  tongue  is  performed  as  described  above  and  if  there 
is  any  mucous  membrane  left  after  the  entire  growth  has  been  freely  excised 
this  is  utilized  for  the  purpose  of  lining  the  floor  of  the  mouth.  After  this 
operation  the  forceps  upon  the  arteries  should  be  loosened  before  the  jaws 
are  united  in  order  that  all  of  the  hemorrhage  may  be  carefully  controlled. 
After  this  has  been  accomplished  the  two  halves  of  the  jaws  are  united  by 
means  of  chromicized  catgut  sutures.  The  floor  of  the  mouth  is  drained 
through  the  lower  end  of  the  incision  and  the  remaining  portion  of  the 
wound  is  carefully  closed. 

This  method  provides  a  very  perfect  exposure  of  the  field  of  operation, 
but  it  is,  of  course,  very  much  more  severe  than  the  operations  which  have 
just  been  described,  and  we  believe  that  it  is  indicated  only  in  cases  in  which 
there  is  involvement  of  the  floor  of  the  mouth. 

RANULA. 

In  operating  for  the  relief  of  ranula  the  object  to  be  attained  is  either 
to  establish  a  new  communication  between  some  portion  of  the  ducts  of  the 
sublingual  glands  involved  and  the  cavity  of  the  mouth,  or  the  complete 
removal  of  the  entire  gland.  The  simplest  method  by  which  to  re-establish 
a  connection  between  the  ducts  of  the  gland  and  the  cavity  of  the  mouth  is 
through  the  use  of  a  seton.  By  applying  a  large-sized  silk  suture  trans- 
versely across  the  ranula  and  tying  this  loosely  so  that  it  does  not  have  a 
tendency  to  cut  away  the  intervening  portion  of  the  mucous  membrane,  one 
may  frequently  secure  the  growth  of  epithelial  cells  in  these  openings 
through  which  the  silk  sutures  passes  so  that  the  lining  of  the  duct  and  the 
cavity  of  the  mouth  become  continuous.  After  this  has  occurred  at  both 
the  point  of  entrance  and  exit  of  the  suture  a  new  suture  may  be  introduced 
through  the  same  openings  and  tied  more  tightly  so  that  the  intervening 
tissue  may  become  absorbed  slowly.  The  opening  formed  between  the  cavity 
of  the  ranula  and  the  mouth  will  thus  become  continuously  lined  with 
mucous  membrane  and  presently  a  permanent  opening  will  be  established. 
This,  however,  will  not  occur  in  every  case  and  it  may  become  necessary, 


PLATE  III. 

EXCISION  OF  TONGUE. 

This  plate  shows  the  base  of  the  tongue  compressed  by  two  strong  silk  ligatures 
which  have  been  applied  by  passing  a  needle  armed  with  a  double  ligature  through 
the  center  of  the  tongue  and  tying  in  halves.  These  ligatures  are  removed  after  the 
diseased  portion  of  the  tongue  has  been  cut  and  the  vessels  at  (aa)  have  been 
separately  ligated  and  the  sutures  (bb)  and  (cc)  have  been  inserted. 

When  the  temporary  ligatures  are  cut  traction  is  made  upon  the  suture  (bb). 
which  will  bring  the  lateral  flaps  into  apposition.  Then  the  sutures  (cc)  are  tied 
and  then  (bb)  and  the  mucous  membrane  is  closed  by  a  continuous  cat-gut  suture. 


SURGERY   OF   THE   HEAD  147 

later,  to  remove  a  considerable  portion  of  the  tissue  between  the  cavity  of 
the  mouth  and  the  ranula,  to  sponge  this  cavity  dry,  and  to  cauterize  it 
either  with  the  actual  cautery  or  with  strong  carbolic  acid,  followed  after  a 
few  minutes  with  strong  alcohol,  or  by  the  use  of  some  other  caustic,  and 
then  by  the  application  of  a  tampon  of  iodoform  gauze  to  the  cavity  thus 
formed.  In  a  number  of  cases  none  of  these  methods  will  succeed  and  then 
it  may  become  necessary  to  dissect  out  the  entire  gland  in  order  to  prevent 
recurrence.  Unless  the  ranula  has  been  severely  inflamed  it  is  usually  pos- 
sible to  find  a  line  of  cleavage  and  to  peel  out  the  mass  in  a  manner  very 
similar  to  the  method  described  in  the  removal  of  a  branchial  cyst.  It  is 
necessary  to  drain  this  cavity  because  its  communication  with  the  cavity  of 
the  mouth  is  likely  to  prevent  preliminary  healing. 

SUBLINGUAL  CYSTS. 

Occasionally  a  dennoid  cyst  is  found  in  the  region  of  the  hyoid  bone 
which  may  be  mistaken  for  a  ranula.  It  may  sometimes  be  differentiated 
from  a  ranula  by  the  presence  within  the  cavity  of  some  epidermal  struc- 
tures, such  as  hair  or  teeth.  The  diagnosis  is  usually  not  made  until  these 
structures  are  encountered  because  of  the  much  greater  frequency  of  the 
presence  of  an  ordinary  -ranula. 

It  is,  of  course,  very  evident  that  nothing  but  the  complete  ex- 
cision of  this  growth  will  accomplish  anything.  There  is  usually  a  line  of 
cleavage  which  can  be  followed  and  the  growth  peeled  out  with  little 
difficulty,  unless  there  has  been  a  chronic  inflammation  causing  extensive 
adhesions.  It  is  necessary  to  take  especial  care  in  dissecting  out  this  growth 
at  the  point  of  its  attachment  to  the  hyoid  bone  because  it  is  at  this  point 
that  one  is  likely  to  leave  a  small  portion  which  will  give  rise  to  a  recurrence. 

EXCISION  OF  TONSILS. 

Complications. 

In  this  climate  a  large  proportion  of  children  and  young  adults  suffer 
from  the  presence  of  hypertrophied  tonsils,  very  commonly  complicated  by 
the  presence  also  of  adenoids  in  the  post-nasal  space.  This  condition  is 
exceedingly  harmful,  because  it  prevents  the  patient  from  normally  perform- 
ing the  functions  of  respiration.  The  amount  of  air  permitted  to  enter  the 
lungs  with  eacli  inspiration  is  greatlv  reduced  unless  the  mouth  be  kept 
open,  and  in  that  case  the  patient  suffers  from  the  inhalation  of  impurities 
otherwise  removed  from  the  air  by  its  passage  through  the  nostrils,  and  by 
inhaling  air  which  has  not  been  modified  either  in  temperature  or  moisture. 

In  many  children  there  is  a  marked  contraction  of  the  chest  due  to  this 
condition,  and  although  the  obstruction  may  later  be  removed  the  lung 
capacity  can  scarcely  be  fully  attained  because  of  the  deformity  which 
already  exists. 

Avenues  of  Infection. 

The  tonsils  and  post-nasal  adenoids  are  also  very  likely  to  become  in- 
fected with  various  pathogenic  micro-organisms,  the  most  common  acute 
forms  being  those  from  ordinary  pus  microbes,  the  diphtheria  bacilli,  the 
micro-organisms  of  influenza  and  the  pneumonia  cliplococcus,  while  a  large 
proportion  of  these  patients  suffer  from  infection  with  tubercle  bacilli.  In 
this  way  the  patient  constantly  carries  about  a  dangerou*  septic  focus.  In 


148  SURGERY  OF   THE  HEAD 

many  of  these  cases  the  infection  from  the  tonsils  and  adenoids  extends  into 
the  Eustachian  tubes  and  gives  rise  to  deafness,  or  it  advances  into  the  mid- 
dle ear  through  the  Eustachian  tube,  producing  suppurative  inflammation  of 
this  cavity,  which  may  further  result  in  an  infection  of  the  mastoid  cells. 
It  is  not  uncommon,  moreover,  for  the  infection  to  become  acutely  intensi- 
fied, resulting  in  tonsillar  abscess  or  an  infection  of  the  deep  tissues  of 
the  neck. 

There  is  scarcely  another  circumscribed  area  in  the  body  from  which 
so  many  secondary  infections  proceed  as  from  the  tonsil.  It  is  one  of  the 
most  common  sources  of  cryptogenetic  infection,  and  frequently  responsible 
for  acute  osteomyelitis.  So  long  as  this  organ  is  normal  there  can  be  no 
doubt  but  that  its  lymphatic  structure  enables  it  to  destroy  a  great  number 
of  pathogenic  micro-organisms,  but  aft^r  it  has  once  become  diseased  and 
filled  with  these  micro-organisms  their  presence  is  a  menace  to  the  health 
of  the  entire  body. 

Technique. 

The  indication  for  treatment  is  unquestionably  plain  in  every  case  in 
which  any  of  the  circumstances  that  have  been  mentioned  exist.  The  por- 
tion of  the  tonsil  which  causes  the  obstruction,  and  which  contains  the 
septic  material,  should  be  removed.  This  may  be  done  very  easily  and  safely 
by  means  of  any  one  of  a  number  of  instruments  which  have  been  especially 
constructed  for  this  purpose,  or  it  can  be  done  by  grasping  the  tonsil  with 
a  pair  of  volsellum  forceps  and  cutting  away  as  much  as  desired  by  means  of 
a  sharp  scalpel  or  by  a  pair  of  sharp,  long-handled  scissors.  It  is  wise  to 
anesthetize  the  mucous  membrane  by  spraying  the  surface  with  a  four  per 
cent  solution  of  cocaine,  in  order  to  make  the  operation  less  painful.  If  a 
tonsillotome  is  used,  it  should  be  applied  from  below  upward  and  from 
behind  forward. 

Methods  of  Hemostasis. 

Unless  the  tonsil  is  acutely  inflamed,  in  which  case  the  operation  should 
be  postponed,  there  is  but  slight  danger  from  hemorrhage.  If  the  organ 
is  drawn  too  tightly  into  the  cavity  of  the  pharynx  before  it  is  cut  off  the 
tonsillar  artery  sometimes  bleeds  considerably.  For  the  purpose  of  con- 
trolling this  hemorrhage  we  have  found  the  following  mixture  most  useful; 
A  teaspoonful  of  acetanilid,  a  tablespoonful  of  alcohol  and  about  two  ounces 
of  water  are  mixed  and  used  as  a  gargle.  This  usually  stops  the  bleeding 
almost  instantly.  If  this  does  not  suffice  pressure  made  with  a  sponge  held 
at  the  end  of  a  pair  of  forceps  for  a  period  of  five  minutes  will  usually  be 
efficient.  Should  this  also  fail  it  is  well  to  insert  a  cat-gut  stitch  about  the 
base  of  the  tonsil  and  to  tie  just  firmly  enough  to  stop  the  hemorrhage. 
There  is  an  instrument  constructed  with  two  padded  branches,  one  of 
which  is  inserted  into  the  mouth  and  placed  directly  upon  the  bleeding  ton- 
sil, and  the  other  at  a  point  opposite  on  the  outside  of  the  neck.  "When  this 
instrument  is  closed  it  makes  a  sufficient  amount  of  pressure  on  the  tonsil 
to  stop  the  bleeding.  In  over  two  thousand  tonsillotomies  that  we  have  per- 
sonally made,  we  have  never  been  compelled  to  use  any  of  these  methods  ex- 
cept the  gargle  with  acetanilid,  alcohol  and  water,  although  in  one  instance 
we  had  quite  a  severe  fright  from  a  patient  who  was  a  hemophiliac  and  be- 
longed to  a  hemophilitic  family,  a  fact  which  had  escaped  our  observation. 

For  the  after-treatment  the  patient  should  be  given  some  mild  anti- 
septic gargle,  which  should  be  used  mornings  and  evenings  for  a  number  of 


SURGERY   OF    THE  HEAD  149 

months  following  the  operation,  in  order  to  improve  the  state  of  the  mucous 
membrane  of  the  pharynx. 

The  Post-nasal  Adenoids. 

In  these  cases  it  is  usually  wise  at  the  same  time  to  curette  away  the 
post-nasal  adenoids  by  means  of  a  flat  curette  with  the  cutting  edge  at 
right  angles  to  the  handle  and  directed  away  from  the  handle.  The  in- 
strument known  in  the  market  as  the  Gottstein  curette  is  most  useful  for 
this  purpose.  The  first  finger  of  the  left  hand  should  be  inserted  above 
the  uvula,  and  with  the  right  hand  the  adenoids  should  be  curetted  away 
with  a  few  quick  motions.  If  the  patient  is  anesthetized  for  this  purpose 
he  should  be  placed  in  the  inverted  position  with  the  head  dependent  from 
the  end  of  the  table.  After  this  has  been  done  an  ordinary  small,  semi- 
sharp  curette  should  be  introduced  through  the  nostril,  and  with  the  finger 
still  above  the  uvula  to  guide  the  spoon,  the  slight  remnants  of  the  adenoids 
which  have  not  been  removed  with  the  flat  curette  may  be  carefully 
scraped  away.  Then  a  piece  of  dry  gauze,  doubled  upon  itself  about  four 
times,  is  introduced  on  the  end  of  the  finger,  and  with  this  the  entire  space 
is  thoroughly  rubbed,  so  as  to  remove  any  small  portions  that  may  still 
be  present. 

Breathing  Exercises. 

It  is  important  that  all  patients  who  have  suffered  from  the  presence  of 
hypertrophied  tonsils  and  adenoids  should  be  given  careful  instruction  in 
breathing  exercises.  They  should  be  taught  to  inhale  fully  through  the 
nose,  with  the  lips  closed,  so  as  to  expand  the  chest  to  its  fullest  extent, 
being  sure  to  make  use  of  the  diaphragm  in  this  exercise.  They  should  then 
force  out  the  air — resisting  with  the  lips — or,  better  still,  they  should  blow 
through  a  small  tube,  with  an  opening  about  two  millimeters  in  diameter, 
until  the  lungs  have  been  emptied  as  much  as  possible.  This  exercise  should 
be  repeated  about  twenty  times  every  morning  and  evening.  It  is  remark- 
able how  greatly  these  patients  are  benefited  by  this  simple  exercise. 
Methods  of  Holding  the  Patient. 

Concerning  the  operation  of  tonsillotomy,  we  wish  to  emphasize  the  fact 
that  it  is  greatly  facilitated  by  having  the  patient's  head  held  perfectly  firm 
between  the  hands  and  against  the  chest  of  an  assistant,  if  the  patient  is  not 
under  the  influence  of  an  anesthetic.  It  is  wise  in  this  case  to  have  the 
patient  drop  his  arms  to  his  sides  and  then  wind  an  ordinary  bed  sheet 
around  his  shoulders  several  times,  so  that  he  cannot  interfere  in  the  opera- 
tion. An  adult  not  under  the  influence  of  an  anesthetic  should  be  seated 
in  a  firm  chair,  an  assistant  should  stand  behind  him,  place  one  hand  on  each 
side  of  his  head  and  force  the  same  backward  against  his  chest,  so  that  the 
latter  is  held  firmly  on  three  sides.  Children  are  best  held  by  seating  them  in 
the  lap  of  an  assistant,  who  takes  their  limbs  between  his  knees  and  holds 
the  child  in  the  manner  described  for  performing  intubation. 

In  using  the  tenaculum  forceps  and  scissors,  or  scalpel,  it  is  necessary 
to  apply  a  gag  between  the  teeth  of  the  patient.  This  is  also  necessary  in 
the  use  of  some  tonsillotomes,  while  with  others  it  is  possible  to  operate 
without  because  the  tonsillotome  itself  prevents  the  teeth  from  closing. 

Limits  of  Excision. 

Much  discussion  has  developed  of  late  as  to  the  extent  to  which  it  is 


I5O  SURGERY   OF   THE  HEAD 

proper  to  remove  tonsils.  For  a  time  it  appeared  as  though  only  the  com- 
plete removal  of  the  gland  could  be  looked  upon  as  a  proper  operation, 
but  at  the  present  time  even  those  who  are  engaged  in  the  special  field  of 
throat  surgery  seem  to  show  signs  of  conversion  to  the  belief  that  the  best 
operation  is  that  which  removes  only  the  diseased  portion  of  the  tonsil  and 
leaves  the  remainder  for  the  future  protection  of  the  patient. 

TUMORS  OF  THE  LIP. 
Angioma. 

Angioma  is  the  most  common  of  all  tumors  in  the  lips  of  children.  The 
growth  appears  as  a  little  purple  mark  usually  not  larger  than  the  head  of  a 
pin.  This  will  increase  in  size  in  time  until  it  may  involve  the  entire  lip. 
Later,  it  may  extend  over  the  face  so  that  quite  a  portion  thereof  may  be 
involved.  After  attaining  some  development  this  growth  is  likely  to  vary 
in  size  with  differences  in  the  temperature  of  the  air  in  which  the  patient 
exists.  While  out  of  doors  in  the  cold  it  will  decrease  so  that  it  can  scarcely 
be  noticed,  but  when  the  patient  is  in  a  warm  room  it  may  increase  so  as 
to  be  quite  troublesome. 

Angioma  of  the  skin  in  this  vicinity,  as  in  every  other  vicinity,  should 
be  removed  at  once  as  soon  as  the  diagnosis  is  made,  because  its  removal  is 
a  very  simple  matter  in  the  early  part  of  its  development,  while  later  on  it 
may  involve  the  reduction  of  a  considerable  deformity.  So  long  as  the 
growth  is  very  small,  not  larger,  for  instance,  than  one  or  two  millimeters 
in  diameter,  a  simple  puncture  with  a  needle  heated  to  white  heat  or  with 
the  fine  knife  of  the  electro-cautery  or  the  fine  point  of  a  Paquelin  cautery, 
will  suffice  to  destroy  an  angioma  permanently.  If  the  growth  has  developed 
to  a  larger  size  it  is  best  to  excise  it  and  to  suture  the  wound  so  that  the 
scar  will  be  in  the  least  offensive  position. 

Wyeth  Method  of  Treatment. 

Recently  Wyeth  has  introduced  a  new  treatment  which  is  especially 
valuable  in  cases  of  nevus  in  which  the  tumor  has  advanced  so  far  in  its 
development  that  its  removal  would  result  in  a  marked  deformity,  or  in 
which  the  operation  would  have  to  be  so  extensive  as  to  endanger  the 
patient's  life.  In  these  cases  a  large  metal  syringe  is  filled  with  boiling  wa- 
ter, which  is  injected  directly  into  the  angioma  through  a  hypodermic  needle 
about  the  size  of  an  ordinary  darning  needle.  As  soon  as  the  surface  of 
the  tumor  begins  to  look  white  the  injection  is  stopped.  We  have  never  in- 
jected more  than  four  ounces  at  one  sitting,  but  in  case  the  tumor  is  large 
we  think  the  amount  might  be  exceeded  with  safety.  Where  the  tumor  is 
large  we  have  found  it  necessary  to  anesthetize  the  patient. 

The  injected  area  becomes  hard  and  somewhat  swollen  directly  after 
the  injection,  but  within  a  week  absorption  begins,  which  continues  for  sev- 
eral weeks.  The  procedure  may  have  to  be  repeated  several  times.  It  is 
best  to  wait  until  the  irritation  has  entirely  subsided  after  one  operation, 
before  it  is  repeated. 

Several  times  when  patients  have  come  from  a  distance  we  have  sent 
them  home  with  directions  to  return  after  several  months  for  further  treat- 
ment. In  some  of  these  cases  the  cure  was  complete  when  they  returned, 
making  further  treatment  unnecessary.  This  experience  has  caused  us  to 
lengthen  the  interval  between  treatments.  The  method  has  great  value  in  a 
class  of  cases  in  which  excision  could  accomplish  little  or  nothing. 


SURGERY   OF   THE   HliAI)  151 

Epithelioma. 

Epithelioma  of  the  lip  occurs  most  commonly  in  the  lower  lip  in  the 
male.  Its  removal  is  indicated  at  the  time  when  it  is  first  noticed.  The 
removal  should  always  be  extensive,  at  least  half  an  inch  of  perfectly 
healthy  tissue  being  excised  in  every  direction.  The  incision  should  be  at 
right  angles  to  the  edge  of  the  lip  and  there  should  be  a  transverse  incision 
joining  the  two  verticals.  All  of  these  incisions  should  extend  entirely 
through  the  lip.  The  transverse  cut  should  extend  beyond  the  vertical  to 
about  one-fourth  the  distance  between  the  two  vertical  incisions,  so  that 
there  is  a  flap  on  each  side  which  can  be  brought  to  meet  its  fellow  and 
then  the  transverse  incision  can  be  sutured  to  the  lower  edge  of  these  flaps. 
A  very  considerable  amount  of  the  lip  may  be  removed  in  this  manner 
without  leaving  any  deformity  to  speak  of.  If  the  entire  lower  lip  is  to  be 
removed  the  defect  should  be  closed  by  means  of  a  plastic  operation. 

In  epithelioma  of  the  lip  the  submaxillary  lymphatic  glands  and  the 
cervical  glands  lying  anteriorly  to  the  sterno-cleido-mastoid  muscle  and 
externally  to  the  deep  jugular  vein  are  the  ones  which  are  most  likely  to 
be  involved.  If  the  epithelioma  is  at  all  advanced  these  glands  should  al- 
ways be  exposed  and  removed. 

Of  late  we  have  subjected  all  of  these  patients  to  prophylactic  X-ray 
treatment  after  the  operation.  Whether  this  will  prove  a  proper  course  to 
pursue  must  be  determined  by  further  experience. 

With  a  thorough  operation  performed  reasonably  early  the  prognosis 
is  very  good.  f 

EPITHELIOMA    OF   THE    FACE. 

What  has  been  said  regarding  epithelioma  of  the  lip  applies  to 
epithelioma  of  any  portion  of  the  face.  The  excision  should  be  done  as 
early  as  possible.  It  should  be  very  liberal  and  the  defect  caused  should 
be  covered  by  means  of  a  plastic  operation  so  that  the  resulting  scars  will 
interfere  as  little  as  possible- with  the  appearance  of  the  patient.  Especial 
care  should  be  taken  to  avoid  tension  upon  the  eyelids  because  this  will  re- 
sult in  an  irritation  of  the  conjunctiva,  which  may  lead  to  serious  trouble. 
By  transversely  suturing  wounds  in  the  vicinity  of  the  eyelids  tension  upon 
the  lids  may  usually  be  avoided. 

During  the  past  seven  years  we  have  subjected  a  number  of  these  patients 
suffering  from  epithelioma  to  X-ray  treatment  before  subjecting  them  to 
operation,  and  have  found  that  perfect  recovery,  without  operation,  as  the 
result  of  the  X-ray  treatment  is  not  at  all  uncommon,  provided  the  epi- 
thelioma is  superficial.  In  any  case  in  which  an  epithelioma  can  be  removed 
without  causing  great  deformity,  and  especially  without  interference  with 
the  eyelids.  We  never  use  the  X-ray  at  the  present  time  until  after  the  wide 
removal  of  the  growth. 


PART   III. 


SURGERY  OF  THE  NECK. 

Lines  of  Incision. 

It  is  important  to  bear  in  mind  the  natural  lines  on  the  surface  of  the 
neck  in  planning  all  surgical  operations  in  this  region  owing  to  the  fact  that 
unsightly  scars  on  the  neck  are  a  source  of  distress  to  the  patient  and 
annoyance  to  the  surgeon. 

Incisions  in  the  direction  of  the  sterno-cleido-mastoid  muscle  are  usually 
less  evident  from  scars  than  those  extending  at  an  angle  with  this  structure, 
or  across  it.  This  is  true  especially  if  the  incision  follows  either  the  anterior 
or  the  posterior  border  of  the  muscle. 

Incisions  extending  across  the  neck  should  be  uniform  on  both  sides 
of  the  neck  if  possible. 

TRAUMATISM  OF  THE  NECK. 

The  most  common  serious  traumatism  is  cutthroat  inflicted  by  the 
patient  himself  during  an  attempt  at  suicide,  or  by  some  enemy. 

In  all  of  these  cases  careful  hemostasis  and  adequate  drainage  are 
elements  which  must  be  provided  for  in  order  to  obtain  reasonably  good 
results. 

Until  hemostatic  forceps  and  ligatures  can  be  applied  the  bleeding 
may  be  controlled  by  placing  the  ends  of  the  fingers  upon  the  bleeding 
vessels.  Only  rarely  will  it  be  possible  to  repair  the  wound  in  the  side  of  a 
vessel.  In  case  one  deep  jugular  vein  is  entirely  severed  the  patient  will 
usually  die  from  loss  of  blood  before  the  surgeon  arrives,  but  if  it  should 
ever  happen  that  the  surgeon  appeared  in  time  to  find  a  patient  still  alive, 
with  one  deep  jugular  vein  entirely  cut  and  the  other  one  nicked,  an  attempt 
to  repair  the  injury  in  the  second  vessel  would  be  proper. 

When  the  pneumogastric  nerve  has  been  severed  the  patient  is  at  once 
in  a  hopeless  condition  from  hemorrhage  from  the  deep  jugular  vein  and 
the  carotid  artery  before  help  can  be  obtained,  consequently  this  condition 
need  not  be  discussed  at  this  point. 

INJURY  TO  THE  TRACHEA. 

When  the  trachea  has  been  cut  the  patient  usually  coughs  and  struggles 
so  violently,  because  of  the  fact  that  he  fills  his  trachea  with  blood  with  every 
inspiration,  that  it  is  difficult  to  control  the  hemorrhage.  It  is,  therefore, 
best  to  place  the  patient  in  the  prone  position,  and  if  this  is  not  possible,  in 
the  sitting  posture,  to  make  digital  compression  of  the  bleeding  vessels  and 
then  to  control  the  hemorrhage  with  hemostatic  forceps.  The  trachea  should 


154  SURGERY    OF    THE    NECK 

then  be  carefully  sutured  with  fine  chromic  catgut,  then  the  vessels  should  be 
ligated. 

An  abundance  of  tubular  and  gauze  drainage  should  be  inserted,  the 
cut  muscles  and  fascia  and  the  overlying  skin  should  be  sutured  and  a 
dressing  applied. 

It  is  seldom  possible  to  unite  the  cut  trachea  so  accurately  that  no  infec- 
tion takes  place  into  the  wound.  If  the  wound  in  the  trachea  is  irregular  it 
may  not  be  possible  to  close  it.  In  that  case  an  intubation  tube  should  be 
inserted,  the  wound  about  this  should  be  tamponed  with  gauze  and  the 
remainder  of  the  operation  carried  out  as  described  before. 

CRUSHING  INJURIES  OF  THE  NECK. 

Crushing  injuries  may  be  so  severe  as  to  cause  fractures  of  the  larynx 
or  the  cartilages  of  the  trachea. 

In  the  event  of  dyspnea  due  to  the  collapse  of  these  structures,  or  to  the 
edema  following  the  injury,  this  must  be  overcome  either  by  the  introduc- 
tion of  an  intubation  tube,  which  will  at  once  provide  a  passage  for  the  air 
and  a  splint  for  the  support  of  the  injured  structures,  or  if  the  injured  part 
cannot  be  reached  in  this. manner,  tracheotomy  and  the  introduction  of  a 
tracheotomy  tube  should  be  employed. 

The  tube  should  be  removed  daily  after  the  third  day,  to  determine  ex- 
perimentally, whether  the  tissues  have  recovered  sufficiently  to  make  it  safe 
to  discard  the  artificial  aid.  The  patient  must,  however,  be  carefully  and 
constantly  watched  for  at  least  24  hours  after  it  seems  safe  to  remove  the 
tube  permanently. 

Many  of  these  patients  do  much  better  if  kept  in  a  sitting  posture.  If 
tracheotomy  is  performed  the  canula  should  be  kept  covered  with  two  to  four 
thicknesses  of  moist  gauze. 

CYSTS    OF    THE    NECK. 

Sebaceous  cysts  occur  here  as  in  all  other  portions  of  the  body  and  must 
be  treated  by  total  excision,  the  same  care  being  taken  to  prevent  leaving 
any  part  of  the  lining  membrane  here  as  elsewhere. 

Dermoid  cysts  occur  in  the  same  way  as  elsewhere,  the  many  im- 
portant changes  that  take  place  during  fetal  life  in  this  region -making  their 
occurrence  somewhat  frequent,  although  these  fetal  remnants  or  inclusions  in 
this  region  usually  take  the  form  of  branchial  cysts  or  thyroglossal  cysts. 

The  treatment  consists  in  careful,  complete  excision. 

Aside  from  these  cysts  we  encounter  lymphangiomata,  bursse,  hydrocele, 
blood  cysts  (aside  from  cysts  of  the  thyroid  gland)  and  hydatid  cysts. 

BRANCHIAL  CYSTS. 

During  the  early  development  of  the  embryo  there  are  four  clefts  on 
each  side  of  the  neck  corresponding  to  the  gills  in  fishes.  These  latter 
become  obliterated,  but  occasionally  the  layers  do  not  unite  perfectly  and 
there  are  left  portions  of  the  epiblastic  tissue  which  have  not  been  destroyed 
and  which  later  secrete  a  fatty  substance  which  will  accumulate  in  this 
defect  and  presently  form  what  is  known  as  a  branchial  cyst. 

The  cyst  develops  slowly,  is  located  underneath  the  skin  and  superficial 
fascia,  fluctuates  upon  palpation,  and  is  not  inflammatory  in  character. 


SURGERY    OF    THE    NECK  155 

The  incision  is  advisably  made  over  the  cyst  in  the  direction  of  some 
of  the  longer  lines  of  the  neck,  and  upon  approaching  the  growth  a  point  will 
be  reached  where  there  is  a  longer  line  of  cleavage  between  the  tissues. 
By  separating  the  cyst  from  the  surrounding  tissues  through  this  latter  it 
can  be  easily  removed.  The  wound  is  closed  in  the  customary  manner  and 
it  heals  kindly.  By  finding  the  natural  line  of  cleavage  one  can  remove  the 
growth  without  any  danger  of  injuring  the  deep  jugular  vein,  in  whose 
proximity  it  exists,  and  even  if  there  has  been  an  inflammatory  condition 
which  has  resulted  in  adhesions  to  the  deep  jugular  vein  the  growth  may 
readily  be  removed  by  careful  dissection  without  danger. 

What  has  just  been  said  may  be  applied  to  all  of  the  other  cysts  men- 
tioned, with  the  exception  of  those  of  the  thyroid  gland,  which  will  be  con- 
sidered later,  and  the  hydatid  cyst  which  is  due  to  a  parasite  and  which  may 
occur  between  the  layers  of  any  of  the  structures  of  the  neck.  This  latter 
form  will  be  recognized  by  the  fact  that  within  a  capsule  of  connective  tissue 
there  is  a  second  cyst  which  is  no  part  of  the  human  body,  but  of  the  parasite. 
This  will  peal  out  spontaneously  as  soon  as  the  connective  tissue  covering  is 
open,  for  there  is  no  connection  between  the  two  structures. 

GOITRE. 

Until  recently  it  has  generally  been  supposed  that  in  this  country 
patients  suffering  from  goitre  rarely  afford  a  characteristic  history  such  as 
they  give  in  portions  of  Switzerland,  France  or  Wales,  where  certain  regions 
seem  to  furnish  a  very  large  proportion  of  patients,  while  other  regions  are 
relatively  free  from  them. 

Apparent  Cause. 

Since  goitre  has  been  studied  more  carefully  in  this  country  many 
regions  have  been  found  where  this  disease  abounds  and  recently  a  number 
of  farms  have  been  investigated  each  supplied  by  a  single  \vell  which  has 
seemed  to  cause  the  appearance  of  goitre,  especially  in  the  younger  members 
of  the  family,  from  drinking  the  water.  Families  having  been  quite  free 
from  this  disease  have  taken  up  their  homes  upon  these  farms,  and  within 
a  year  several  members  thereof  have  become  afflicted,  then  changing  their 
residence  the  children  who  were  born  later  remained  free  from  the  disease. 

One  of  the  instances  quoted  frequently  shows  the  influence  of  this 
infected  water  so  clearly  that  it  seems  wise  to  repeat  it  here. 

Example. 

Two  private  schools  located  only  a  few  miles  from  each  other  obtained 
their  drinking  water  from  two  different  springs.  Both  schools  obtained  their 
pupils  from  many  distant  points.  The  pupils  of  one  of  these  schools  devel- 
oped goitre  regularly  while  the  pupils  of  the  other  school  as  regularly  re- 
mained free  from  goitre.  When  the  water  supply  of  the  first  school  was 
changed  the  pupils  also  remained  free  from  goitre  while  attending  this 
institution.  Kocher  claims  that  if  water  is  boiled  it  loses  its  infectious  char- 
acter and  becomes  quite  as  harmless  as  that  from  any  pure  source.  Whether 
this  is  due  to  the  precipitation  of  lime  salts  contained  in  the  water,  or  to 
some  microorganisms,  has  not  yet  been  determined. 

It  seems,  however,  imperative  that  families  in  which  several  goitres 
have  occurred  be  advised  to  use  water  for  drinking  purposes  from  an  entirely 
different  source  of  supply,  or  else  that  they  invariably  boil  all  drinking  water 


156  SURGERY    OF    THE    NECK 

from    the    well    which    is    supposed    to   have    caused    the    goitres    already 
developed. 

Characteristics. 

The  enlargement  of  the  thyroid  gland  more  commonly  appears  about  the 
age  of  puberty  than  at  any  other  time.  It  also  occurs  during  gestation  in 
quite  a  number  of  patients.  It  happens  much  more  frequently  in  this  country 
in  females  than  in  males.  It  may  affect  any  one  or  two,  or  all  of  the  lobes  of 
the  thyroid  gland.  When  the  middle  lobe  is  involved  there  is  frequently  an 
enlargement  extending  down  behind  the  upper  end  of  the  sternum,  causing 
quite  severe  pressure  upon  the  anterior  surface  of  the  trachea.  The  patient 
may  seek  relief  because  of  the  deformity  caused  by  the  presence  of  the 
tumor ;  because  of  its  weight  on  the  neck ;  or  because  of  the  obstruction  in 
the  trachea  produced  by  pressure  from  a  lobe  of  this  gland.  The  enlarge- 
ment may  be  due  to  an  increase  in  the  parenchyma  of  the  gland,  or  one  oi 
the  lobules  may  be  distended  with  gelatinous  or  serous  fluid  giving  rise  to 
the  formation  of  a  cyst,  or  there  may  be  a  fibrous  degeneration  of  a  portion 
of  the  gland  or  the  development  of  a  fibrous  tumor,  or,  especially  in  patients 
advanced  in  age,  there  may  develop  a  malignant  growth,  either  carcinoma, 
sarcoma,  endothelioma  or  angioma.  The  enlargement  may  also  be  due  to  a 
simple  infection,  with  its  skin  edema. 

The  diagnosis  of  a  tumor  of  the  thyroid  is  simple  because  of  the  form 
and  location  of  this  gland ;  also  from  the  fact  that  if  the  patient  swallows 
the  gland  rises  with  the  larynx,  being  firmly  attached  to  the  trachea.  An 
enlargement  due  to  an  inflammatory  condition  can  be  easily  recognized  be- 
cause of  the  symptoms  accompanying  inflammatory  conditions  in  any  part 
of  the  body.  Malignant  growths  are  characterized  by  an  induration  of  the 
tissues,  which  is  not  present  in  a  benign  growth  of  the  thyroid  gland.  The 
age,  and,  usually,  a  rapid  development  of  cachexia,  are  important  conditions 
to  be  considered  in  making  this  differential  diagnosis. 

Hygiene  and  Internal  Medication. 

In  young  girls  the  glandular  enlargement  commonly  subsides  if  gen- 
eral hygienic  measures  are  employed.  This  may  be  somewhat  facilitated  by 
administering,  three  times  a  day,  tablets  containing  five  grains  each  of  the 
desiccated  thyroid  gland  of  sheep,  the  doses  being  somewhat  varied  accord- 
ing to  the  condition  of  the  patient.  General  tonics  are  indicated  in  these 
cases.  In  older  patients  the  absorption  of  these  growths  is  sometimes  further 
facilitated  by  the  hypodermic  injection  of  from  sixty  to  one  hundred  and 
twenty  drops  of  a  five  per  cent,  solution  of  carbolic  acid  in  water,  directly 
into  the  enlarged  lobe.  This  should  be  done  once  each  week  at  first  and  less 
frequently  later  on.  The  same  hygienic  and  tonic  measures  should  be 
employed  as  in  younger  patients. 

Tn  those  instances  wherein  the  goitre  continues  to  increase  in  size 
notwithstanding  the  hygienic,  dietetic,  medicinal  and  injection  treatment  just 
named  surgical  removal  of  the  gland  may  be  indicated,  provided  the  patient 
suffers  because  of  the  incident  pressure,  from  pain,  dyspnea,  interference 
with  the  recurrent  laryngeal  nerve  or  in  case  the  weight  of  the  part  becomes 
burdensome  or  the  deformity  repulsive. 

EXOPHTHALMIC    GOITRE. 

From   the    standpoint   of   the   surgeon   the   diagnosis   of   exophthalmic 


SURGERY    OF    THE    NECK  157 

goitre,  in  cases  coming  properly  under  surgical  treatment,  is  not  a  difficult 
matter  because  no  case  properly  belongs  in  this  class  unless  treatment  with 
rest,  hygiene,  diet  and  internal  medication  has  either  failed  altogether  or  has 
failed  to  relieve  the  patient  permanently  of  the  disease. 

As  early  as  1786  Parry  gave  a  clear  description  of  the  symptoms  of  this 
disease.  This  was  repeated  by  Graves  in  1835  and  five  years  later  with  great 
clearness  by  Von  Basedow,  and  since  then  innumerable  times  by  hundreds 
of  clinicians. 

The  following  may  serve  as  a  short,  concise  summary  of  the 
symptomatology. 

Summary  of  Characteristic  Symptoms. 

I.  Exophthalmos.  2.  Tachycardia.  3.  Tremor.  4.  Muscular  weakness. 
5.  Nervous  excitability.  6.  Vertigo.  7.  Graefe's  symptoms  (in  directing 
the  eye  downward  the  lower  margin  of  the  upper  eyelid  does  not  follow  the 
line  of  vision  normally,  but  lags  behind  or  follows  in  an  irregular  spastic 
manner).  8.  Stellwag's  symptoms  (retraction  of  upper  lid  together  with 
infrequent  winking).  9.  Paroxysmal  dyspnea.  10.  Intermittent  vomiting 
without  apparent  exciting  cause,  n.  Intermittent  diarrhea  without  appar- 
ent exciting  cause.  12.  Intermittent  sweating  without  apparent  exciting 
cause.  13.  Intermittent  mental  depression  without  apparent  exciting  cause. 
14.  Psychic  excitation  increases  the  gravity  of  the  condition.  15.  Physical 
or  mental  fatigue  increases  the  gravity  of  the  condition.  16.  The  admin- 
istration of  thyroid  extract  increases  the  gravity  of  condition.  17.  The 
administration  of  iodides  increases  the  gravity  of  the  condition.  18.  In 
advanced  cases  there  is  practically  always  emaciation. 

Any  one,  or  any  group,  of  these  symptoms  may  be  prominent  early, 
while  others,  especially  the  goitre  and  the  exophthalmos  may  be  late  in 
appearing,  or  may  be  developed  to  so  slight  an  extent  that  they  are  only 
noticed  after  the  examining  physician's  suspicion  of  the  presence  of  the 
disease  has  been  aroused  by  the  prominence  of  some  of  the  less  common 
conditions.  The  one  symptom  of  tachycardia,  however,  seems  to  be  present 
in  every  case. 

Blood  Analysis. 

Kocher  has  found  some  fairly  uniform  conditions  in  the  blood  examina- 
tions made  in  cases  suffering  from  exophthalmic  goitre,  but  they  are  also 
present  in  a  number  of  other  diseases.  There  seems  to  be  lessened  coagula- 
bility of  the  blood  ;  the  polyneutrophilcs  are  decreased  from  75  per  cent,  to 
35  per  cent.,  while  the  lymphocytes  are  increased  from  25  per  cent,  to  75 
per  cent,  in  individual  cases  on  the  day  before  operation,  while  on  the  day 
after,  the  neutrophiles  increased  from  42  per  cent,  to  89.2  per  cent.,  whereas 
the  lymphocytes  decreased  from  48  per  cent,  to  2.7  per  cent. 

Kocher  comes  to  the  conclusion  that  there  is  an  increase  in  lymphocytes 
and  a  decrease  in  lecocytes  before  the  operation  and  vice  versa  after  opera- 
tion. He  characterizes  exophthalmic  goitre  as  a  hyperthyreosis  with 
glandular  hyperplasia,  lymphocytosis  and  lymphatic  disturbances  of  the 
gland. 

The  increase  in  lymphocytes,  however,  was  more  often  relative  than 
absolute :  the  total  number  of  leucocytes  being  normal  or  rather  low. 

Kocher's  conclusions  are  based  on  careful  blood  examinations  in  58 
cases. 


158  SURGERY    OF    Til  1C    N  KC  K 

Value  of  Early  Diagnosis. 

From  the  practical  standpoint,  however,  it  should  be  stated  that  the 
diagnosis  is  made  in  almost  every  case  a  long  time  before  the  surgeon  is 
consulted.  Indeed,  until  very  recently,  too  long  a  period  of  time  has  inter- 
vened between  the  original  diagnosis  and  the  surgical  treatment  in  many  of 
these  cases,  and  too  much  stress  cannot  be  laid  upon  the  importance  of  an 
early  operation  in  all  instances  in  which  a  permanent  cure  is  not  obtained 
by  internal  treatment  pursued  a  reasonable  length  of  time. 

This  fact  is  most  forcibly  insisted  upon  by  Kocher,  Mayo  and  all  other 
clinicians  who  have  had  a  large  experience  in  the  surgical  treatment  of  these 
cases,  and  one  that  should  be  impressed  especially  upon  the  family  physician. 

Although  much  attention  has  been  given  to  the  complications  affecting 
the  nervous,  the  circulatory  and  the  digestive  systems,  because  of  their  being 
directly  dependent  upon  the  disease,  it  must  be  remembered  that  ex- 
ophthalmic goitre  is  not  uncommonly  complicated  by  diseases  of  any  portion 
of  the  body.  Even  myxedema  has  been  described  as  a  complication  by 
Simonds,  Gooding,  Faure  and  a  few  others,  although  such  disease  is  plainly 
the  result  of  a  lack  of  physiological  activity  of  the  thyroid  gland,  while 
exophthalmic  goitre  is  supposed  to  be  due  to  a  hyperthyroidism,  according 
to  Kocher.  cr  to  a  toxin  caused  by  an  excessive  amount  of  normal  or 
abnormal  thyroid  secretion,  according  to  Moebius,  while  Oswald  and  a  few 
others  think  there  is  a  thyroid  insufficiency.  To  our  minds  the  beautiful 
description  of  pathological  findings  by  McCallum  are  convincing  of  the  fact 
that  there  is  indeed  always  a  condition  present  which  must  result  in  hyper- 
throidism,  no  matter  what  the  exciting  cause  may  be,  and  this  we  think  is 
plainly  borne  out  by  the  clinical  picture. 

Technique. 

In  order  to  produce  a  clear  idea  of  a  reasonably  safe  operation  in 
exophthalmic  poitre  it  may  be  well  to  describe  the  various  steps  successively. 

It  is  important  to  prepare  patients  with  a  pulse  exceeding  120  beats  per 
minute,  or  those  with  a  pulse  which  lacks  uniformity,  by  absolute  rest  in 
bed,  mild  sedatives,  a  meat-free  but  nourishing  diet,  quiet  surroundings, 
absence  of  all  psychic  excitation,  which  according  to  the  observations  and 
anhml  experimentations  of  Crile  is  capable  of  producing  hyperthyroidism  by 
a  discharge,  in  some  way  either  directly  or  indirectly,  into  circulation  of  an 
excessive  amount  of  thyroid  secretion,  which  in  itself  may  cause  death. 

Four  grains  of  hydrobromate  of  quinine,  in  capusules,  given  after 
meals  three  times  daily,  seems  to  be  of  some  benefit  in  the  preparatory  treat- 
ment of  these  cases.  A  considerable  proportion  may  improve  so  much  under 
this  treatment  that  an  operation  may  become  unnecessary. 

Tepid  baths  and  any  other  means  of  making  the  patient  comfortable  and 
contented  are  useful.  If  general  anesthesia  is  employed  this  should  be  given 
so  as  to  not  excite  the  patient. 

In  order  to  prevent  infection  two  precautions  are  important:  first,  the 
careful  covering  of  the  patient's  hair,  and  second,  guarding  against  infection 
from  the  mouth  and  nose.  It  is  an  easy  matter  for  a  patient  to  fill  her  own 
wound  with  infectious  material  from  her  mouth  or  nose  if  these  are  not 
under  the  careful  supervision  of  some  assistant  who  gives  his  entire  atten- 
tion to  this  matter.  If  the  operation  is  performed  under  cocaine  anesthesia 
this  protection  can  readily  be  accomplished  bv  placing  a  dozen  thicknesses 
of  sterile  gauze  in  the  form  of  a  roller  bandage  over  the  patient's  mouth 


PLATE  Ilia. 
THYKOIDECTOMY 

Showing  large  incision  with  primary  ligation  of  superior  thyroid  artery  and 
vein  at  c :  the  retracted  scerno-cleido-mastoid  muscle  at  b  and  the  dislocated 
gland  a. 


SURGERY    OF    THE    NECK  l6l 

and  nose  and  around  the  head.  The  patient  will  be  able  to  breathe  through 
this  covering  but  the  air  expelled  from  the  nose  and  mouth  will  be  filtered  on 
its  way  through  these  layers  of  gauze. 

If  ether  is  used  the  patient  should  first  be  thoroughly  anesthetized  while 
in  the  horizontal  position,  then  the  head  of  the  table  should  be  elevated  to 
30  degrees,  the  mouth  and  nose  covered  with  gauze  in  the  manner  just  de- 
scribed, then  the  operation  may  be  completed  without  the  administration  dT 
any  further  amount  of  anesthetic,  as  the  elevation  of  the  head  results  in 
cerebral  anemia  and  this  in  turn  deepens  the  anesthesia  to  such  an  extent 
that  it  will  last  until  the  operation  is  completed  if  the  latter  be  done  with 
reasonable  speed. 

The  curved  transverse  symmetrical  incision  of  Kocher  is  now  made  with 
its  convexity  directed  downwards,  its  lowest  portion  being  2  cm.  above  the 
upper  end  of  the  sternum.  The  skin  flap,  together  with  the  platysma,  is 
reflected  upward  to  a  joint  just  above  the  upper  attachment  of  the  sterno- 
thyroid  muscles.  These  are  now  cut  across  at  their  upper  end  and  reflected 
downward.  This  gives  an  excellent  field  of  operation.  It  is  now  possible  to 
grasp  the  superior  thyroid  vessels  between  two  pairs  of  forceps  and  to  cut 
and  ligate  both  ends. 

In  the  meantime  the  superficial  vessels  which  have  been  encountered 
have  all  been  grasped  between  two  pairs  of  hemostatic  forceps  and  have 
been  cut  and  ligated. 

Having  severed  the  superior  thyroid  vessels  en  the  side,  of  course,  on 
which  an  enlargement  is  found  or  on  which  there  are  irregular  nodules  to 
which  the  disease  has  been  attributed,  it  is  .an  easy  matter  to  dislocate  the 
lobe  forward.  This  brings  into  view  the  inferior  thyroid  vessels.  These  are 
again  grasped  between  two  pairs  of  hemostatic  forceps,  then  cut  and  ligated. 

At  this  point  it  is  very  important  not  to  grasp  the  vessels  too  near  their 
origin,  especially  on  the  right  side,  for  fear  of  injuring  the  recurrent 
laryngeal  nerve  or  the  lower  one  of  the  parathyroid  glands.  Both  of  these 
structures  are  located  between  the  thyroid  gland  and  the  trachea  near  this 
point,  and  both  may  easily  be  avoided  if  the  above  plan  is  followed. 

The  lobe  is  then  dissected  up,  care  being  taken  to  leave  the  posterior 
portion  of  the  capsule  undisturbed  and  with  it  the  recurrent  laryngeal  nerve 
and  parathyroid  gland.  The  isthmus  is  now  lifted  up  and  this  exposes  the 
inferior  thyroid  vessels  of  the  other  side.  These  should  usually  be  treated 
precisely  as  those  on  the  side  which  has  just  been  finished,  unless  the  disease 
is  entirely  confined  to  the  one  side.  In  most  instances  it  is  best  to  remove  one 
entire  lobe,  with  the  exception  of  the  posterior  capsule.  The  isthmus  and 
about  the  lower  half  of  the  other  lobe  should  usually  be  removed,  also 
without  disturbing  the  posterior  capsule. 

This  disposes  of  both  inferior  thyroid  arteries  and  veins  as  well  as  the 
superior  vessels  on  one  side.  During  the  entire  operation  all  manipulations 
are  made  with  the  greatest  gentleness  in  order  not  to  press  contents  of  the 
gland  into  the  circulation  or  into  the  wound  for  fear  of  causing  acute 
hyperthyroidism. 

At  the  same  time  great  care  is  taken  to  prevent  hemorrhage,  because 
Kocher  has  pointed  out  the  toxic  effect  of  blood  absorbed  by  the  wound 
surfaces.  For  the  same  reason  every  precaution  is  taken  to  stop  any  oozing 
into  the  wound  after  the  operation, 

The  muscles  are  then  carefully  sutured  in  place  so  as  to  reduce  the 


l62  SURGERY    OF     i  till    NECK 

deformity  to  a  minimum.  A  small  drain  is  inserted  through  the  lowest  point 
in  the  wound,  or,  better  still,  through  a  small  opening  2  cm.  below.  The 
skin  wound  is  closed  with  the  greatest  accuracy  in  order  to  prevent 
deformity. 

Detail  of  Minimum  Dangers. 

By  performing  this  operation  in  such  a  systematic  manner  the  dangers 
to  the  patient  are  reduced  to  a  minimum.  Indeed,  all  of  the  recognized 
dangers  are  practically  eliminated.  Ether  anesthesia  which  is  permanently 
stopped  before  beginning  to  operate,  removes  all  danger  from  this  source. 
It  also  disposes  of  the  danger  from  post-operative  ether  pneumonia  inas- 
much as  the  patient  exhales  practically  all  of  the  ether  during  the  operation. 
The  arrangement  of  the  gauze  bandage  to  the  mouth  and  nose  prevents  in- 
fection from  this  source.  Injury  to  parathyroids  and  recurrent  laryngeal 
nerves  is  carefully  avoided.  The  gentle  manipulations  of  the  gland  and 
accurate  hemostasis  prevent  difficulty  from  thyroid  toxins,  and  the  remain- 
ing portion  of  the  gland  prevents  cachexia  strumipriva. 

There  are,  however,  cases  which  are  too  weak  to  bear  even  this  simple 
operation  and  which  seem  to  be  unable  to  make  further  progress  without 
operative  aid.  In  these  it  is  well  to  follow  the  suggestions  of  Kocher  to 
ligate  first  one  vessel  under  cocaine  and,  after  a  few  days,  another,  until  it 
seems  safe  to  remove  the  diseased  gland. 

Tuholsky  in  an  admirable  paper  suggests  the  plan  of  preventing  the 
toxic  effect  of  thyroid  secretion  by  ligating  both  superior  and  inferior 
thyroid  veins.  This  is  worth}-  of  the  attention  of  experimental  research 
laboratory  workers  in  this  field. 

Lowered  Mortality. 

For  statistics  the  contributions  of  Mayo,  Kocher  and  Crile  should  be 
consulted.  They  show  one  very  important  practical  point  which  we  wish  to 
emphasize,  in  connection  with  many  other,  namely,  that  the  operative  mor- 
tality has  decreased  enormously  both  with  the  accumulation  of  the  total 
surgical  experience  in  this  field  and  with  the  enlarged  surgical  experience 
of  each  individual  operator.  In  the  history  of  all  surgical  progress  whenever 
this  has  occurred  the  time  was  near  for  uniform  methods  to  become 
established. 

The  first  case  of  exophthalmic  goitre  we  personally  operated  has  now 
been  perfectly  well  since  1895.  The  patient  was  a  young  woman  22  years  of 
age,  with  typical  symptoms,  becoming  constantly  worse  under  internal  treat- 
ment. There  was  marked  exophthalmos,  severe  nervous  symptoms,  only  a 
moderately  enlarged  nodular  lateral  lobe  and  marked  tachycardia.  Her 
pulse  had  remained  above  140  beats  per  minute  during  several  weeks  of 
observation  previous  to  operation. 

The  rapid  and  permanent  disappearance  of  all  of  these  symptoms  after 
operation  encouraged  me  to  employ  surgical  treatment  in  all  cases  which 
did  not  recover  permanently  by  internal  treatment,  and  such  a  course  has 
been  pursued  ever  since  that  time. 

Recent  Advancements. 

During  the  past  few  years  this  subject  has  been  taken  from  the  field  of 
experimental  surgery  and  placed  among  those  which  are  looked  upon  as 
fairly  well  settled  by  all  surgeons  who  have  had  an  opportunity  to  build  up 
a  fair  clinical  experience  in  this  especial  branch.  This  change  has  been 


SURGERY    OF    THE    NECK  163 

accomplished,  especially  during  the  past  five  years,  through  the  investiga- 
tions of  the  internist  in  the  direction  of  diagnosis,  through  the  physiologist 
in  the  study  of  living  pathology  (largely  through  experimental  work),  and 
by  the  surgeon  in  simplifying  the  technique  of  surgical  treatment.  So  thor- 
oughly have  all  these  points  been  studied  that  it  may  now  be  reasonably 
expected  that  the  primary  diagnosis  having  been  made,  certain  cases  may  be 
relieved  permanently  by  internal  treatment,  while  others  will  be  improved 
only  temporarily  by  internal  treatment,  and  that  this  latter  class  should  be 
subjected  to  surgical  treatment  at  an  early  stage  of  the  disease,  before  the 
effects  of  the  toxins  have  hopelessly  impaired  especially  the  muscles  of  the 
heart  and  the  nervous  system.  Under  such  circumstances  it  may  be  expected 
that  there  will  remain  only  a  small  proportion  of  cases  that  will  not  be 
benefited  either  by  medical  or  sugical  treatment,  that  still  a  smaller  propor- 
tion of  the  extremely  violent  cases  will  succumb  to  the  disease  without  an 
operation,  and  only  a  very  small  percentage  die  after  operation. 

Experience  has  shown  that  with  early  diagnosis  and  proper  selection 
of  cases  the  mortality  after  surgical  operation  is  extremely  small  and  that 
this  percentage  is  decreasing  from  year  to  year  so  that  it  will  be  reasonable 
to  expect  an  operative  mortality  of  less  than  one  per  cent,  within  a  few 
rears  in  the  hands  of  competent  surgeons. 

In  the  same  manner  unfavorable  late  results  are  sure  to  decrease,  as 
already  the  most  dreaded  ones  have  been  practically  eliminated.  We  no 
longer  encounter  post-operative  cases  of  cachexia  strumipriva,  tetany, 
paralysis  of  the  vocal  cords,  and  but  very  rarely  recurrence  of  the  symptoms 
of  the  disease  itself. 

Conclusions. 

i.  The  diagnosis  of  cases  of  exophthalmic  goitre  regarded  as  suitable 
for  surgical  treatment  is  relatively  easy  and  should  be  made  early.  2.  All 
cases  of  exophthalmic  goitre  which  are  not  relieved  permanently  by  rest, 
hygienic,  dietetic  and  medicinal  treatment  should  be  treated  surgically  before 
there  has  been  irreparable  harm  done  to  important  structures.  3.  This  is 
especially  to  be  borne  in  mind  in  connection  with  a  class  of  cases  that  respond 
readily  to  non-surgical  treatment  only  to  relapse  at  once  upon  the  slightest 
strain.  4.  The  dangers  of  the  operation  depend  largely  upon  the  harm  done 
by  the  disease  before  the  operation.  5.  These  dangers  may  be  eliminated  by 
early  operation  and  by  preliminary  treatment  with  rest,  hygiene  and  diet. 
6.  The  operative  danger  lies  in  the  anesthetic,  sepsis,  acute  hyperthyroidism, 
tetany,  cachexia  strumipriva,  injury  to  the  recurrent  laryngeal  nerve, 
hemorrhage  and  shock.  7.  All  of  these  dangers  may  be  eliminated  easily 
with  reasonable  skill  and  attention  to  details.  8.  The  patient  should  receive 
carefully  directed  after-treatment,  with  rest,  hygiene  and  diet,  following  the 
operation  until  especially  the  blood,  the  nervous  system  and  the  heart 
have  thoroughly  recovered  from  the  effects  of  the  disease.  9.  All  psychic 
excitation  should  be  prevented  before,  and  for  a  long  time  after,  the 
operation. 

\Yhat  has  been  said  concerning  the  technique  of  thyroidectomy  for  the 
relief  of  exophthalmic  goitre  is  true  of  the  operation  for  simple  goitre,  with 
the  one  difference  that  the  latter  class  of  patients  is  usually  in  a  much  better 
general  state  of  health.  The  greatest  amount  of  clanger  in  the  former  class 
comes  from  the  effect  the  hyperthyroidism  characterizing  the  disease  has 


164  SURGERY    OF    THE    NECK 

already  had  upon  the  tissues  of  the  patient's  nervous  and  circulatory  systems 
before  coming-  under  the  care  of  the  surgeon. 

By  neglecting  all  of  the  precautions  advised  against  the  production 
of  hyperthyroidism  during  the  operation  it  is  possible  to  cause  this  condition 
occasionally  even  in  operations  for  the  relief  of  simple  goitre;  but  with 
reasonable  care  this  can  always  be  avoided. 

MALIGNANT  GROWTHS  OF  THE  THYROID  GLAND. 

Results    of    Operations    Unsatisfactory. 

Operations  for  the  relief  of  malignant  growths  of  the  thyroid  have 
been  so  unsatisfactory  in  their  results  that  it  seems  doubtful  whether  they 
should  be  undertaken.  It  is  to  be  hoped  that  our  experience  in  the  use  of 
the  X-rays  will  continue  to  be  favorable  in  these  cases,  but  at  the  present 
time  nothing  positive  can  be  said  in  this  regard.  If  a  removal  is  made  the 
same  steps  are  to  be  carried  out  that  have  just  been  described. 

In  several  cases  we  have  found  small  malignant  growths  in  what  was 
supposed  to  be  a  simple  goitre,  and  these  cases  have  been  free  from  recur- 
rence, but  in  those  in  which  the  diagnosis  was  possible  before  the  operation 
we  have  never  been  so  fortunate  and,  according  to  Crile,  this  has  been  the 
general  experience  of  surgeons. 

If  the  enlargement  in  the  thyroid  is  circumscribed,  taking  the  form  of  a 
fibroid  tumor  or  a  cyst,  usually  colloid,  or  a  circumscribed  adenoma,  it  is 
unnecessary  to  remove  an  entire  lobe  of  the  gland.  In  this  case  an  incision 
is  made  over  the  enlargement  in  such  a  manner  as  to  produce  as  little  de- 
formity as  possible.  Then  the  capsule  of  the  gland  is  split,  care  being  taken 
to  grasp  portions  of  the  capsule  between  two  pairs  of  forceps  before  cutting 
it  in  order  to  prevent  hemorrhage.  When  the  nodule  in  question  is  exposed 
a  point  of  cleavage  between  it  and  the  remaining  portion  of  the  gland  is 
sought  and  the  mass  is  readily  enucleated  either  with  the  ringer,  a  Kocher's 
director  or  a  blunt  dissector.  In  case  of  troublesome  hemorrhage  tension  is 
made  upwards  upon  the  forceps  which  have  been  applied  to  the  capsule 
and  a  few  stitches  passed  through  the  walls  of  the  cavity  from  which  the 
growth  has  been  removed,  and  tied  with  just  sufficient  tension  to  overcome 
the  bleeding.  The  capsule  is  then  sutured  and  the  skin  is  sutured  over  it. 
If  the  cyst  is  of  large  size  the  whole  lobe  of  the  gland  should  be  thoroughly 
exposed. 

If  the  precautions  which  have  been  mentioned  in  this  article  are  borne 
in  mind  the  operation  is  relatively  very  safe,  unless  it  is  clone  during  a  con- 
dition of  severe  dyspnea,  which  may  occur  at  any  time  in  cases  in  which 
there  is  much  pressure  upon  the  trachea  from  an  acute  edema  of  the  growth. 
In  such  an  event  it  is  frequently  unsafe  to  anesthetize  the  patient  and  then 
it  is  best  to  cocainize  the  line  of  skin  incision  with  a  one  per  cent,  solution 
of  cocaine  and  to  infiltrate  the  deeper  layers  with  a  one-tenth  of  one  per 
cent,  solution  of  cocaine  in  a  normal  salt  solution.  The  pressure  is  almost 
always  due  to  an  enlargement  of  the  middle  lobe,  and  it  is  consequently 
wise  to  make  a  horseshoe-shaped  incision  through  the  skin  with  the  con- 
vexity downward,  to  grasp  the  vessels  rapidly  between  two  pairs  of  forceps, 
to  cut  them,  and  as  soon  as  the  middle  lobe  is  exposed,  to  insert  into  it 
sharp-pointed  retractors  with  at  least  four  teeth,  the  ordinary  catspaw 
variety  being  the  most  useful,  and  with  these  to  lift  the  lobe  upwards  and 
thus  dislodge  it  from  its  location  behind  the  sternum  where  it  causes  the 


SURGERY    OF    THE    A'ECK  165 

pressure  which  gives  rise  to  the  condition  of  dyspnea.  After  this  lobe  has 
once  been  dislodged  the  dyspnea  ceases  and  the  remaining  steps  of  the 
operation  may  be  completed  without  difficulty  and  without  danger  to  the 
patient.  We  have  found  it  necessary  to  operate  upon  patients  in  this  con- 
dition in  the  sitting  posture  as  in  the  recumbent  position  they  were  entirely 
unable  to  breathe. 

TUBERCULOUS  GLANDS  OF  THE  NECK. 
Direction  of  Infection. 

In  the  treatment  of  tuberculous  glands  of  the  neck  the  first  considera- 
tion must  be  the  removal  of  tuberculous  material  from  the  body  in  order 
to  prevent  further  infection.  The  glands  which  are  first  infected  have 
progressed  furthest  in  the  changes  which  are  due  to  the  presence  of  tubercle 
bacilli.  In  the  earlier  stages  the  gland  is  hypertrophied  and  contains 
numerous  tuberculous  foci-  which  may  be  separated  by  normal  gland  tissue, 
or  a  number  of  these  foci  may  have  developed  so  closely  together  that  they 
will  form  one  nodule.  Presently  more  and  more  of  these  foci  will  develop 
in  close  proximity  and  then  the  nutrition  of  this  portion  of  the  gland  will 
become  impaired  and  caseous  degeneration  will  take  place.  It  is  important 
to  bear  this  in  mind  because  in  this  way  one  can  recognize  the  direction  from 
which  the  infection  has  taken  place,  which  in  turn  will  affect  the  plan  of 
treatment.  The  source  of  infection  is  most  commonly  found  in  tubercular 
foci  which  have  developed  in  the  tonsils.  This  infection  may  occur  from 
particles  of  food  containing  tubercle  bacilli  becoming  lodged  upon  the 
surfaces  and  within  crypts  of  the  tonsils ;  from  particles  of  sputa  containing 
bacilli  lodged  in  the  same  manner ;  or  from  mucus  descending  from  the 
posterior  nares  containing  bacilli  which  have  been  lodged  in  this  mucus  from 
dust  in  the  air. 

Patients  suffering  from  tuberculous  glands  of  the  neck  have  usually 
lived  in  surroundings  in  which  the  dust  was  likely  to  contain  tubercle  bacilli 
owing  to  the  careless  disposition  of  sputum  of  patients  suffering  from  tuber- 
culosis of  the  lungs,  or  they  have  been  in  the  habit  of  drinking  unsterilized 
milk. 

Causative  Influences. 

In  our  own  practice  children  living  under  unhygienic  surroundings  in 
houses  containing  tuberculous  patients,  and  children  coming  from  the  farms 
where  they  live  to  a  very  large  extent  upon  uncooked  milk,  are  the  two 
classes  in  which  we  have  found  this  condition  most  commonly.  In  the  vast 
majority  of  these  patients  we  have  been  able  to  determine  the  presence  of 
tuberculous  foci  in  the  tonsils  in  children,  or  in  the  apex  of  the  lungs  in 
adults.  These  facts  are  of  very  great  importance  because  if  they  are  not 
recognized  our  treatment  is  not  likely  to  benefit  the  patient  greatly,  as  a 
reinfection  is  almost  certain  to  occur  as  soon  as  the  patient  is  exposed  to  the 
influences  which  first  gave  rise  to  the  disease. 

Clinical  Instance. 

A  young  lady  eighteen  years  of  age,  living  at  home  and  taking  care  of 
her  three  younger  sisters,  gives  the  following  history,  which  is  typical  of 
these  cases  in  many  respects,  and  may  well  serve  to  illustrate  the  etiology 
and  diagnosis  of  this  disease. 


l66  SURGERY    OF    THE    NECK 

Her  mother  died  at  the  age  of  forty-two  from  tuberculosis  of  the  lungs, 
when  our  patient  was  but  twelve  years  of  age.  The  father  is  in  excellent 
health ;  her  three  younger  sisters  are  also  in  perfect  health.  The  patient 
suffered  from  whooping-cough,  measles  and  scarlet  fever  while  still  young, 
having  the  last  named  disease  at  the  age  of  six.  After  this  time  she  suffered 
frequently  from  a  mild  form  of  tonsilitis,  the  tonsils  remaining  greatly 
enlarged  and  swelling  to  such  an  extent  as  to  almost  close  the  pharynx, 
making  it  difficult  to  breathe  through  the  nose  whenever  they  were  at  all 
congested.  Shortly  after  her  mother  died  she  first  noticed  a  small  swelling 
beneath  her  left  ear.  This  varied  in  size,  but  was  always  larger  when  she 
suffered  from  colds.  Several  months  ago  her  general  condition  became 
impaired  and  she  became  quite  anemic.  At  about  the  same  time  she  noticed 
several  swellings  beneath  the  first  one  and  a  further  swelling  beneath  the 
angle  of  the  jaw  on  the  left  side.  These  have  increased  in  size  slowly  but 
constantly,  the  latest  one  being  located  directly  above  the  clavicle. 

The  patient  is  fairly  well  nourished ;  her  appetite  is  fair ;  her  tongue 
is  clean  ;  the  bowels  are  fairly  regular ;  the  temperature  is  normal ;  pulse 
100,  full  and  strong;  her  heart,  lungs  and  kidneys  are  normal.  She  is  quite 
markedly  anemic.  There  is  a  series  of  swellings  extending  from  a  point  be- 
neath the  mastoid  process  along  the  anterior  border  of  the  sterno-cleido- 
mastoid  muscle  down  to  the  clavicle ;  several  nodules  beneath  the  angle  of 
the  jaw  on  the  left  side;  also  a  deep  swelling  apparently  underneath  the 
sterno-cleido-mastoid  muscle.  None  of  these  swellings  fluctuate.  The 
examination  of  the  blood  shows  the  amount  of  hemoglobin  decreased,  but 
otherwise  it  is  normal. 

This  history  is  a  typical  one  in  cases  of  tuberculosis  of  the  cervical 
glands.  Scarlet  fever  and  measles  are  so  common  in  this  community  that 
it  would  be  difficult  to  prove  a  connection  between  these  conditions  and 
tubercular  glands  of  the  neck,  but  in  a  majority  of  these  cases  one  will  find 
that  a  certain  amount  of  infection  remains  in  the  tonsils,  which  in  turn  un- 
doubtedly makes  the  tuberculous  infection  of  the  lymphatic  glands  of  the 
neck  more  likely. 

In  this  case  the  oldest  child  was  associated  with  her  mother  during  the 
latter's  sickness  from  pulmonary  tuberculosis,  the  younger  children  being 
cared  for  by  relatives.  This  would  account  for  the  infection  of  the  oldest, 
and  for  the  freedom  from  infection  in  the  three  younger  daughters.  The 
slowness  in  the  progress  of  the  disease  may  be  accounted  for  by  the  fact  that 
the  child  was  naturally  strong  and  healthy  and  that  she  has  always  lived 
under  good  hygienic  surroundings,  with  the  exception  of  the  time  she  was 
with  her  sick  mother.  The  same  conditions  account  for  the  good  health 
of  her  younger  sisters. 

The  history  contains  one  feature  which  is  quite  common  in  these  cases, 
viz.,  that  relating  to  the  variation  in  the  size  of  the  glands  during  the  early 
part  of  the  infection  ;  the  increase  in  size  corresponding  to  the  time  when 
the  patient  was  suffering  from  cold — in  other  words,  during  the  acute 
reinfection.  Had  this  patient  been  subjected  to  proper  treatment  at  this 
time  it  is  quite  possible  that  the  existing  swelling  in  the  glands  would  have 
disappeared  entirely,  but  one  cannot  make  a  positive  statement  regarding 
this,  as  the  existing  initial  infection  is  much  more  severe  in  some  cases 
than  in  others. 

For  four  months  this  patient  has  been  treated  very  properly  by  means  of 


SURGERY    OF    THE    NECK  167 

internal  medication.  She  has  been  given  tonics,  her  work  in  school  has  been 
interrupted,  and  she  has  been  out-of-doors  a  great  share  of  the  time.  Her 
household  cares  have  been  reduced.  She  has  also  received  some  form  of 
creosote,  which  is  supposed  to  have  a  direct  effect  upon  the  tuberculous 
infection.  Her  general  health  has  been  greatly  improved  in  the  meantime, 
but  there  has  been  a  slight  increase  in  the  size  of  the  swellings,  although 
this  has  been  very  slow. 

There  are  two  reasons  why  in  this  case  this  form  of  treatment  has  not 
resulted  in  a  reduction  in  the  size  of  these  swellings,  or  possibly  a  cure. 
In  the  first  place  the  primary  source  of  infection  is  in  the  tuberculous  foci 
contained  in  her  greatly  enlarged  tonsils.  Secondly,  the  degree  of  infection 
in  the  lymphatic  glands  of  her  neck  has  already  advanced  to  such  an  extent 
that  its  absorption  is  not  to  be  expected.  It  will  consequently  become  neces- 
sary for  us  to  relieve  her  by  means  of  operative  treatment. 

Technique. 

In  this  operation  we  must  consider. 

ist.  The  deep  jugular  vein,  as  its  injury  might  result  in  the  introduc- 
tion of  air  into  the  circulation,  causing  air-embolism  and  death. 

2nd.     The  cartoid  arteries  and  the  pneumogastric  nerve. 

3rd.  Some  of  the  more  important  branches  of  the  spinal  accessory 
nerve  must  be  preserved,  because  their  injury  results  in  marked  deformity, 
due  to  paralysis  of  the  trapezius  muscle,  and  consequent  discomfort  to  the 
patient. 

4th.  The  scar  should  be  so  placed  as  to  cause  in  itself  as  little  de- 
formity as  possible. 

An  incision,  therefore,  is  made  along  the  anterior  edge  of  the  sterno- 
cleido-mastoid  muscle,  from  the  mastoid  process  down  to  the  clavicle.  The 
superficial  fascia  is  carefully  dissected  back  on  each  side  of  this  incision. 
The  first  incision  severs  the  external  jugular  vein,  which  should  at  once  be 
caught  and  ligated  on  each  side  of  the  division,  or  it  is  still  better  to  grasp 
the  vein  between  two  pairs  of  forceps  and  to  cut  it  after  it  has  been  thus 
caught,  and  then  ligate  at  once.  The  edges  of  the  wound  should  now  be 
carefully  retracted  and  a  dissection  begun  at  the  lower  end  of  the  incision. 
This  should  be  carried  on  carefully  until  the  sheath  of  the  deep  jugular  vein 
is  reached,  which  may  be  followed  upwards  until  the  entire  vein  has  been 
laid  bare  from  the  clavicle  to  the  angle  of  the  jaw.  The  lymphatic  glands 
are  closely  adherent  to  the  sheath  of  the  vein,  but  with  the  vein  plainly  in 
view  there  is  no  danger  of  injuring  it  if  the  dissection  is  pursued  carefully. 

About  an  inch  below  the  angle  of  the  jaw  we  find  several  enlarged 
glands.  This  is  at  the  point  at  which  the  facial  vein  enters  the  deep  jugular. 
It  is  a  favorite  location  for  a  tuberculous  lymphatic  gland.  Great  care  must 
be  taken  in  dissecting  out  this  gland  as  one  is  in  danger  of  injuring  the  facial 
or  the  deep  jugular  vein,  or  both.  In  this  instance  it  is  possible  to  secure  a 
sufficient  amount  of  space  without  making  a  transverse  incision,  but  occa- 
sionally it  is  necessary  to  carry  the  wound  some  distance  below  the  lower 
jaw,  and  parallel  with  it,  in  order  to  remove  all  the  submaxillary  glands. 
It  is  not  unusual  to  find  the  submaxillary  lymphatic  gland  infected  with 
tuberculosis,  necessitating  its  removal.  If  this  is  necessary  it  is  best  to  grasp 
the  facial  artery  and  vein  between  two  pairs  of  hemostatic  forceps  and  cut 
between  these  just  below  the  point  where  they  enter  the  submaxillary 
salivary  gland,  because  in  this  way  one  can  prevent  some  hemorrhage  and 


l68  SURGERY    OF    THE    NECK 

the  clouding-  of  the  field  of  operation.  To  the  outer  side  and  behind  the 
deep  jugular  vein  the  lymphatic  glands  are  also  enlarged  and  we  will  carry 
our  dissection  upwards  behind  the  edge  of  the  sterno-cleido-mastoid  muscle. 
About  half  the  distance  between  the  lower  and  the  upper  attachment  of  the 
sterno-cleido-mastoid  muscle,  or  at  a  point  at  which  the  trapezius  muscle 
approaches  the  former,  several  branches  of  the  spinal  accessory  nerve  will 
be  encountered.  It  is  important  to  preserve  these  as  their  destruction  will 
result  in  a  drooping  of  the  shoulder  and  an  atrophy  of  the  muscles  of  the 
lower  part  of  the  neck.  In  making  the  dissection  from  below  upwards  the 
superficial  cervical  nerve  will  be  encountered  passing  transversely  across 
the  sterno-cleido-mastoid  muscle  about  its  middle.  A  little  above  this  point 
the  spinal  accessory  nerve  passes  out  of  the  sterno-cleido-mastoid  muscle  and 
thence  backward  and  downward  into  the  trapezius  muscle.  The  superficial 
cervical  nerve  being  larger  and  more  superficial  serves  as  a  guide  to  the 
more  important  spinal  accessory.  The  latter  should  be  carefully  dissected 
out  to  its  insertion  in  order  to  avoid  an  accidental  injury. 

We  have  now  disposed  of  all  of  the  enlarged  glands  with  the  excep- 
tion of  those  underneath  the  upper  portion  of  the  sterno-cleido-mastoid 
muscle.  These  may  be  approached  by  making  a  transverse  incision  through 
the  sterno-cleido-mastoid  muscle,  by  splitting  the  latter  longitudinally,  or, 
better  still,  by  dissecting  the  muscle  entirely  free  and  drawing  it  out  of  the 
field  of  operation  by  means  of  retractors.  The  last  of  the  three  methods 
mentioned  will  be  followed  here  as  it  does  the  slightest  amount  of  injury  to 
this  important  muscle,  while  the  other  methods  are  undoubtedly  both  harm- 
ful and  unnecessary. 

All  the  infected  glands  have  now  been  carefully  removed.  It  is  our 
practice  to  apply  strong  compound  tincture  of  iodine  to  all  the  raw  sur- 
faces with  the  expectation  of  destroying  thereby  any  bacilli  still  remaining 
in  these  tissues,  and  also  with  the  idea  of  stimulating  the  tissues  to  increased 
healing.  Other  surgeons  use  different  antiseptics  for  the  same  purpose,  and 
still  others  use  none  at  all,  and  apparently  all  are  equally  successful. 

It  is  wise  to  supply  some  means  of  escape  for  the  serum,  which,  during 
the  first  twenty-four  hours,  will  accumulate  from  the  large  raw  surfaces 
In  order  that  the  flaps  may  not  be  separated  by  the  accumulating  serum, 
after  once  uniting,  we  will  insert  a  small  drain  in  the  lower  angle  of  the 
wound,  and  then  will  unite  the  edges  of  the  wound,  using  the  utmost  care  to 
secure  a  most  perfect  coaptation,  because  in  this  way  we  will  be  able  to 
avoid  as  much  as  possible  the  formation  of  a  disfiguring  scar. 

\\'e  are  in  the  habit  of  uniting  the  fascia  with  a  separate  row  of  catgut 
sutures  in  order  to  avoid  a  depression  of  the  scar. 

Removal  of  Tonsils  and  Adenoids. 

The  most  important  part  of  the  operation  still  remains,  for  were  we  to 
leave  this  patient  in  her  present  condition  she  would  be  virtually  worse  off 
than  when  we  started  the  operation,  as  in  removing  the  diseased  lymphatic 
glands  we  have  undoubtedly  removed  many  normal  ones  which  might  serve 
to  protect  the  patient  against  further  invasions  through  the  same  source  of 
infection — which  still  remains — in  other  words,  we  have  not  only  relieved 
our  patient  of  her  diseased  lymphatic  glands,  but  also  of  many  lymphatic 
glands  which  if  left  in  place  would  serve  to  protect  her.  We  must,  there- 
fore, remove  the  cause  of  infection  in  this  case,  which  exists  in  the  tubercular 
foci  in  her  tonsils,  and  in  the  adenoids  in  the  post-nasal  space.  We  therefore 


SURGERY    OF    THE    NECK  169 

place  the  patient  in  the  inverted  position  and  permit  her  head  to  hang  back- 
ward over  the  end  of  the  table.  We  then  insert  a  gag  between  her  teeth  to 
keep  the  mouth  open,  and  then  remove  both  tonsils ;  and  by  means  of  a 
broad,  flat,  post-nasal  curette  we  curette  away  the  adenoids,  protecting  the 
uvula  and  soft  palate  by  inserting  the  left  index  finger.  In  order  to  com- 
plete the  removal  of  these  adenoids  we  further  insert  a  small,  ordinary, 
moderately  blunt  curette  through  the  nostril,  and,  guiding  the  spoon  with 
the  left  index  finger  in  the  pharynx,  curette  away  all  of  the  remaining 
granulations.  This  step  is  taken  first  through  one  nostril  and  then  through 
the  other  until  the  pharynx  is  perfectly  free  from  adenoids.  At  the  same 
time  we  examine  the  patient's  mouth  and  if  she  has  any  decayed  teeth  to  act 
as  a  source  of  infection  they  will  be  removed. 

After-treatment  Important. 

In  these  cases  it  is  especially  important  that  the  after-treatment  be 
carefully  supervised  by  the  surgeon.  One  of  the  most  important  features 
of  this  after-treatment  consists  in  instructing  the  patient  to  take  breathing 
exercise  systematically.  It  is  our  practice  to  have  these  patients  inhale 
through  the  nose  with  closed  lips,  filling  the  chest  completely,  and  then 
exhale  while  they  resist  with  the  lips.  The  most  convenient  way  of  accom- 
plishing the  latter  step  is  by  placing  between  the  lips  a  small  tube  about  two 
millimeters  in  diameter.  This  exercise  should  be  practiced  at  least  twenty 
times  in  the  morning  and  again  as  many  times  in  the  evening. 

The  hygienic  surroundings  of  the  patient  should  be  favorable.  The 
living  and  sleeping  room  should  be  high,  dry  and  sunny.  The  food  should 
be  nourishing  and  simple  and  the  patient  should  have  an  abundance  of  out- 
door exercise.  Tonics  and  anti-tubercular  remedies  should  be  given  sys- 
tematically until  full  recovery,  and  a  patient's  habits  should  be  so  formed 
that  it  becomes  natural  for  him  to  live  hygienically. 

It  is  far  more  important  that  these  last  mentioned  directions  be  carried 
out  than  that  the  tuberculous  glands  be  removed,  because  if  these  hygienic 
measures  are  carefully  followed  the  patient  will  usually  live  much  longer 
and  be  in  much  better  health,  even  though  the  glands  be  not  removed,  than 
would  obtain  if  the  glands  were  removed  after  the  most  perfect  method 
and  no  attention  paid  to  the  dangers  by  reinfection.  The  plan  which  must 
consequently  result  in  restoring  these  patient?  permanently  to  good  health, 
and  to  the  lengthening  of  their  lives  to  the  greatest  possible  degree,  consists 
in  removing  all  of  the  infected  glands,  as  well  as  the  primary  foci  of  infec- 
tion whenever  this  is  possible ;  in  improving  the  hygienic  conditions  and 
the  food ;  and  in  administering  tonics  and  anti-tubercular  remedies ;  all  of 
which  can  only  be  accomplished  by  impressing  the  patient  with  the  im- 
portance of  the  conditions  and  the  consequences. 

The  principles  laid  down  above  regarding  the  operation  for  removal 
and  the  after-treatment  of  tuberculous  glands  in  the  neck  will  apply  to 
tuberculous  glands  in  general  without  regard  to  the  location  in  the  body. 
It  is  characteristic  for  these  glands  to  be  adherent  to  the  veins  wherever 
they  may  occur,  because  the  lymphatic  glands  which  are  most  likely  to  be 
infected  by  tuberculosis  are  all  located  in  close  proximity  to  the  larger  veins 
of  the  body. 

General  Prognosis. 

If  the  tuberculous  glands  of  the  neck  which  do  not  disappear  under 


I/O  SURGERY    OF    THE    NECK 

internal  and  hygienic  treatment,  and  after  the  removal  of  the  focus  from 
which  the  original  infection  has  taken  place,  are  removed,  and  the  internal 
and  hygienic  after-treatment  which  has  been  outlined  here  has  been  followed, 
then  the  prognosis  in  these  cases  is  good  both  as  regards  immediate  and 
permanent  results.  If  broken  down  tuberculous  glands  of  the  neck  are  not 
removed  the  degeneration  may  proceed  to  calcification  of  the  caseous 
portion  of  the  gland  and  the  patient  may  still  recover  or  adhesions  may 
take  place  between  the  gland  and  surrounding  structures,  and  the  accumu- 
lation of  tuberculous  material  may  result  in  a  sufficient  amount  of  pressure 
necrosis  of  the  overlying  tissues  to  cause  a  perforation  through  the  skin  and 
spontaneous  drainage.  This  may  continue  for  a  considerable  time,  or  may 
be  relieved  by  means  of  an  operation.  In  the  former  case  the  patient 
remains  ill  for  a  long  period,  and  if  a  spontaneous  cure  results  it  will  be 
accompanied  by  a  considerable  amount  of  deformity. 

Again,  the  infection  may  progress  from  one  set  of  glands  to  another 
until  all  of  the  cervical  lymphatics  have  become  involved.  Then  the  space 
occupied  by  the  lymphatics  extending  from  the  neck  into  the  axilla  behind 
the  clavicle  may  be  affected  and  there  may  be  a  tuberculous  infection  of  the 
axillary  lymphatic  glands ;  or,  again,  the  infection  may  extend  along  the 
median  line  into  the  cavity  of  the  chest.  Each  of  these  conditions  is,  of 
course,  much  more  serious  than  the  original  infection ;  consequently  the 
danger  should  be  interrupted  before  it  has  progressed  to  one  or  the  other 
of  these  unfortunate  results. 

During  the  past  five  years  so  much  progress  has  been  made  in  the 
hygienic  and  dietetic  treatment  of  pulmonary  tuberculosis  that  all  that  has 
been  said  above  should  be  supplemented  by  directing  the  patient  to  live  pre- 
cisely as  he  would  be  directed  to  were  he  suffering  from  incipient  pulmonary 
consumption.  He  should  live,  and  especially  sleep,  out-of-doors,  eat  an 
abundance  of  eggs,  beef  and  mutton  and  drink  at  least  two  quarts  of  milk 
daily,  from  tuberculin-tested  cows,  or,  if  ordinary  milk  is  used,  sterilize  it 
without  boiling.  A  sterilizing  apparatus  may  be  improvised  in  the  poorest 
kitchen  by  the  use  of  a  fruit  jar  and  an  ordinary  kettle  in  which  a  cloth  has 
been  placed  to  prevent  the  heat  from  cracking  the  fruit  jar.  The  latter, 
containing  the  milk,  should  of  course  be  placed  in  the  water  in  the  kettle 
before  very  much  heat  is  applied. 

The  water  should  boil  about  the  fruit  jar  at  least  twenty  minutes. 

The  patient  should  also  eat  an  abundance  of  cooked  vegetables,  cereals 
and  cooked  fruits,  with  bread  and  butter,  but  none  of  the  non-nutritious 
condiments.  Alcohol  in  every  form  is  harmful  and  should  be  tabooed. 

Use  of  Beck's  Bismuth  Paste. 

In  old  cases  that  have  suppurated  and  in  which  there  are 
resulting  sinuses  the  injection  of  a  sufficient  amount  of  Beck's  bismuth  paste 
every  two  to  six  days,  so  as  to  fill  the  sinus  without  overdistending  it,  and 
closing  the  external  opening  with  a  gauze  plug,  will  speedily  disinfect  the 
discharge  and  the  sinuses  will  usually  heal  in  a  short  time. 

The  tonsils  and  adenoids  must  of  course  be  removed  in  these  as  in  the 
other  cases,  to  prevent  reinfection. 

Later  it  is  advisable  to  excise  the  disfiguring  scars  marking  the  position 
of  the  sinuses,  and  to  close  the  defect  carefully  so  as  to  reduce  the  de- 
formity to  a  minimum.  It  is  best  not  to  perform  this  secondary  operation 
until  after  the  sinus  has  been  healed  for  at  least  one  year,  for  fear  of  having 


SURGERY    OF    THE    NECK  I/I 

the  edges  of  the  wound  break  down  after  suturing,  leaving-  an  unsightly 
scar. 

HODGKIN'S    DISEASE. 

The  lymphatic  glands  of  the  neck  frequently  undergo  a  form  of  en- 
largement and  degeneration  which  is  probably  also  infectious  in  its  char- 
acter, but  in  which  we  are  not  able  at  the  present  time  to  determine  the 
nature  of  the  infection.  The  condition  is  rarely  entirely  confined  to  the 
neck,  the  lymphatic  glands  in  other  portions  of  the  body  being  enlarged  also. 
The  glands  are  harder  and  usually  more  closely  grouped  than  in  tuberculosis. 
The  patient  is  anemic  or  cachectic  in  appearance.  Upon  removal  of  a  gland 
it  is  found  to  contain  a  uniform  structure  in  which  there  are  no  circum- 
scribed tubercles  or  foci  of  caseation.  These  glands  contain  an  abundance 
of  connective  tissue  and  the  spherical  cells  of  the  normal  lymph  gland  will 
be  seen  to  have  lost  their  characteristic  appearance. 

This  condition  may  be  distinguished  from  the  enlargement  of  the  same 
glands  due  to  leukemia  by  the  fact  that  the  blood  does  not  show  the  marked 
increase  in  leucocytes  that  characterizes  the  latter  disease. 

The  removal  of  the  enlarged  lymph  glands  in  Hodgkin's  disease  does 
not  benefit  the  patient  except  when  their  presence  interferes  with  respiration 
by  pressure  upon  the  trachea.  In  a  considerable  number  of  these  cases  there 
has  been  a  rapid  disappearance  of  the  glands  under  treatment  with  the 
X-ray,  but  it  will  be  necessary  to  follow  them  further  before  anything 
positive  can  be  said  on  this  subject. 

Hygiene  and  diet  should  be  carefully  regulated.  The  patient  should 
also  receive  tonics  and  from  one-half  to  two  grains  of  sodium  arsenate  given 
hypodermically  each  day  in  a  five  per  cent,  solution  of  distilled  water.  This 
seems  to  be  beneficial. 

ENLARGEMENT  OF  CERVICAL  LYMPHATIC  GLANDS  COMPLICATED 

BY  LEUKEMIA. 

The  mode  of  differentiating  between  this  condition  and  the  other  two 
forms  of  enlargement  of  the  cervical  lymphatics  has  just  been  described. 
The  treatment  in  these  cases  should  not  be  surgical  in  character. 

LYMPHO-SARCOMA  OF  THE  NECK. 

This  disease  is  differentiated  from  the  other  conditions  which  are  similar 
in  appearance,  and  that  have  just  been  described: 

1st.     By  the  absence  of  a  history  of  tubercular  infection. 

2nd.  By  the  fact  that  the  surrounding  tissues  are  invaded  very  soon 
after  the  beginning  of  the  disease. 

3rd.     By  the  rapidity  of  its  development :   and 

4th.     By  the  early  appearance  of  cachexia. 

The  excision  of  a  sarcoma  of  the  neck  is  the  only  treatment  which  has 
heretofore  seemed  to  promise  anything  for  the  patient.  From  the  anatom- 
ical conditions  present  in  this  region  an  extensive  removal  is,  of  course,  not 
possible,  and  consequently  these  cases,  with  very  few  exceptions,  have  been 
hopeless;  and  still  there  are  undoubtedly  a  few  that  have  recovered  per- 
manently. The  after-treatment  with  the  X-ray  seems  to  be  of  great  impor- 
tance. We  have  seen  severe  cases  in  which  recurrent  nodules  have  disap- 
peared permanently. 


IJ2  SURGERY    OF    THE    NECK 

CARCINOMA   OF  THE   LMYPHATIC    GLANDS   OF  THE   NECK. 

This  is  always  secondary  to  the  presence  of  carcinoma  of  some  portion 
of  the  face,  pharynx,  parotid  gland,  or  tonsil,  which  will  differentiate  it  from 
the  conditions  which  have  just  been  described.  Thorough  surgical  removal 
is  the  only  treatment  that  promises  anything,  with  the  possible  exception  of 
treatment  by  the  X-ray.  The  condition  is,  therefore,  almost  hopeless. 

In  operating  every  structure,  with  the  exception  of  the  pneumogastric 
nerve,  that  may  be  even  slightly  involved  must  be  excised.  We  prefer  to 
make  the  excision  with  the  cautery  in  order  to  prevent  reinfection  with  the 
carcinoma  tissue  and  toxine. 

These  cases  should  all  receive  vigorous  after-treatment  with  the 
X-ray. 

SEPTIC  INFECTION  OF  DEEP  TISSUES  IN  THE  NECK. 

Quite  frequently  in  infants,  and  occasionally  in  adults,  there  is  a  septic 
infection  of  the  deep  tissues  of  the  neck  resulting  from  an  infection  of  the 
tonsil  or  some  portion  of  the  pharynx.  The  condition  is  violent  in  its  onset 
and  there  is  a  severely  indurated,  extensive  swelling  which  usually  begins 
in  the  upper  portion  of  the  neck  and  extends  downward.  The  induration  is 
often  so  severe  that  fluctuation  cannot  be  determined.  Pus,  however,  is 
always  to  be  found  in  the  deeper  tissues  and  its  removal  by  means  of  an 
incision,  and  the  subsequent  application  of  drainage  and  a  moist  antiseptic 
dressing,  results  in  a  rapid  recovery.  The  incision  should  be  made  carefully, 
because  there  is  sometimes  a  displacement  of  the  anatomical  structures,  and 
unless  care  is  taken  these  are  likely  to  be  injured  during  the  operation. 

After  the  incision  has  been  made  through  the  skin  and  superficial  fascia 
it  is  often  best  to  separate  the  deep  tissues  bluntly  until  the  small  abscess  is 
reached,  rather  than  to  run  the  risk  of  injuring  important  parts,  especially 
the  deep  jugular  vein. 

LIGNOUS  INFILTRATION  OF  THE  NECK. 

Lately  a  condition  has  been  classified  separately  from  other  extensive 
infections  of  the  neck  because  of  the  extreme  board-like  hardness  of  the 
tissues  incident.  The  affection  progresses  rather  slowly  but  causes  profound 
distress  because  of  the  fact  that  the  tissues  are  quite  unyielding,  having 
much  the  appearance  of  infiltrating  skin  cancer — cancer  encuirosse. 

The  tissues  cut  like  cartilage  and  although  they  are  evidently  filled  with 
serum  and  with  leucocytes  the  surfaces  do  not  secrete  fluid  like  that  found 
upon  incising  skin  in  the  presence  of  ordinary  edema. 

The  tissues  should  be  freely  incised  and  the  deep  structures  freely 
separated,  much  the  same  as  heretofore  described.  Usually  a  focus  of  infec- 
tion will  be  found  containing  a  few  drops  of  pus.  A  large,  hot,  moist 
dressing  consisting  of  two  parts  of  a  saturated  solution  of  boric  acid  and 
one  part  of  alcohol,  should  be  applied,  and  this  should  be  covered  with  an 
impermeable  substance  like  rubber  tissue,  held  in  place  by  a  roller  bandage. 
The  prognosis  is  favorable. 

TORTICOLLIS. 

Space  will  permit  us  to  discuss  only  the  treatment  of  the  non-spas- 
modic form  of  torticollis,  which  depends  upon  a  shortening  of  the  sterno- 
cleido-mastoid  muscle. 


SURGERY    OF    THE    NECK  173 

The  form  of  treatment  which  we  have  found  most  satisfactory  consists 
in  carefully  dissecting  out  the  sterno-cleido-mastoid  muscle,  or  what  is  left 
of  it,  together  with  the  cicatricial  tissue  which  may  compose  a  portion  of  the 
muscle.  Having  laid  bare  the  entire  muscle  it  is  split  in  halves  longi- 
tudinally to  a  point  within  an  inch  of  its  upper,  and  to  the  same  distance 
with  regard  to  its  lower  extremity.  Each  half  is  now  permitted  to  remain 
attached  to  one  end,  while  at  the  other  end  of  the  incision  through  the 
muscle  it  is  cut  loose  so  that  the  upper  attachment  carries  one-half  of  the 
muscle  and  the  lower  attachment  the  other  half.  The  head  is  now  turned 
so  that  the  chin  reaches  the  shoulder  of  the  side  on  which  the  short  muscle 
exists,  in  order  to  determine  the  length  desired,  and  the  two  ends  are  united 
by  means  of  a  number  of  fine  catgut  sutures.  After  the  head  is  turned  back 
so  that  the  chin  is  opposite  the  sternum  the  sutured  muscle  will  appear  con- 
siderably relaxed.  It  will  give  the  impression  of  being  quite  a  little  too  long. 
It  is  now  covered  with  the  superficial  fascia  by  means  of  a  row  of  catgut 
sutures  and  the  skin  is  sutured  over  all.  This  leaves  the  diseased  side 
entirely  without  tension.  The  muscle  usually  fills  up  quite  rapidly,  and,  in 
my  experience,  the  deformity  has  not  recurred  and  the  function  has  been 
very  satisfactory. 

Recently  we  have  made  an  incision  through  the  skin  along  the  upper 
edge  of  the  clavicle,  thoroughly  exposing  the  sternal  as  well  as  the  clavicular 
attachment  of  the  sterno-cleido-mastoid  muscle.  All  of  these  attachments 
were  then  severed  entirely  and  the  muscle  was  followed  upward  and  all 
adhesions  were  cut  which  seemed  in  any  way  to  interfere  with  an  absolutely 
free  movement  of  the  neck  and  head.  Then  two  small  drains  were  inserted 
into  the  angles  of  the  wound  which  was  then  sutured.  The  wound  in  the 
neck  made  by  this  operation  is  sometimes  very  deep,  as  unless  all  fibres  are 
severed  the  operation  must  fail. 

The  chief  advantage  in  this  operation  lies  in  the  fact  that  no  scar  is 
produced  on  the  exposed  portion  of  the  neck.  The  disadvantage  rests  in  the 
fact  that  any  surgeon  who  has  not  witnessed  the  operation  at  the  hands  of 
a  trained  operator  is  not  likely  to  do  the  work  with  sufficient  thoroughness  to 
give  a  satisfactory  result. 

SPASMODIC   TORTICOLLIS. 

Where  this  condition  is  absolutely  limited  to  spasmodic  contractions  of 
one  sterno-cleido-mastoid  muscle  it  is  proper  to  sever  the  spinal  accessory 
nerve  supplying  this  muscle,  but  in  every  case  that  has  come  under  our  care 
other  muscles  were  involved  and  consequently  such  an  operation  could  not 
relieve  satisfactorily.  In  severe  cases  the  condition  is,  however,  so  distress- 
ing that  resection  of  the  nerves  supplying  the  muscles  involved  would  be 
justified,  in  case  the  patient  would  be  willing  to  exchange  his  distress  for  the 
resulting  paralysis. 

TRACHEOTOMY. 

Since  the  introduction  of  diphtheria  antitoxin  tracheotomy  is  performed 
almost  entirely  for  the  relief  of  obstruction  to  respiration  due  to  the  intro- 
duction of  foreign  substances  into  the  larynx,  such  as  the  inspiration  of  ker- 
nels of  corn,  or  other  objects,  by  children  at  their  play,  or  the  forcing  down 
of  the  diphtheritic  membrane  in  the  attempt  to  introduce  an  intubation  tube. 
It  is  also  done  for  the  removal  of  foreign  substances  that  have  been  inspired, 
and  for  the  relief  of  obstruction  to  the  larynx  due  to  malignant  growths. 


174  SURGERY    OF   THE    NECK 

Technique. 

The  seat  of  the  operation  may  be  chosen  either  above  or  below  the 
isthmus  of  the  thyroid  gland,  or  should  the  patient  be  in  danger  of  asphyxia- 
tion, necessitating  a  very  rapid  operation,  the  incision  may  be  made  directly 
through  the  isthmus  of  the  thyroid  gland,  the  latter  having  previously  been 
grasped  between  two  pairs  of  hemostatic  forceps.  When  the  operation  has 
to  be  performed  with  extreme  rapidity  it  is  best  to  place  the  patient  in  the 
inverted  position  with  the  head  dependent  so  that  any  blood  which  it  may 
not  be  possible  to  control  at  once  will  gravitate  away  from  the  opening 
in  the  trachea  and  will  not  be  inspired.  If  sharp  tenacula::  are  at  hand 
it  is  wise  to  plunge  two  of  these  directly  through  the  skin  into  the  trachea 
on  each  side  of  the  median  line  and  then  to  make  an  incision  directly  into  the 
trachea  with  one  sweep  of  the  knife  and  to  hold  the  incision  open  by  drawing 
upon  the  tenaculae  while  artificial  respiration  is  performed.  In  the  mean- 
time the  bleeding'  vessels  may  be  caught,  and  if  a  tracheotomy  tube  is  at 
hand  it  may  be  inserted.  This,  however,  is  not  at  all  an  attractive  operation 
and  should  never  be  done  except  in  the  presence  of  absolute  necessity.  If 
the  operation  can  be  done  leisurely  the  important  points  to  be  considered  are : 

i st.  To  control  the  hemorrhage  in  the  successive  steps  before  the  blood 
vessels  are  cut.  An  incision  should  be  made  in  the  median  line  and  each 
blood  vessel  caught  with  two  pairs  of  hemostatic  forceps  as  it  appears  in  the 
wound,  and  then  the  incision  should  be  continued.  In  this  manner  the  oper- 
ation should  proceed  until  the  rings  of  the  trachea  are  plainly  in  view ; 
then  all  the  vessels  should  be  carefully  ligated  and  any  further  bleeding 
points  caught  with  forceps  and  tied,  and  then  the  two  tenaculse  should  be 
passed  through  one  of  the  tracheal  rings  to  either  side  of  the  median  line  and 
the  trachea  incised  longitudinally,  one,  two  or  three  cartilaginous  rings 
being  cut  transversely. 

2nd.  Should  it  occur  that  the  operation  is  performed  for  the  removal  of  a 
foreign  body  from  the  trachea  or  larynx  it  is  wise  to  have  an  experienced 
assistant  prepared  to  catch  the  foreign  body  the  moment  the  trachea  is 
opened,  inasmuch  as  such  a  body  is  frequently  forced  out,  together  with  a  lot 
of  tenacious  mucus,  the  moment  the  trachea  is  incised.  After  this  there  is 
usually  a  deep  inspiration  which  may  again  draw  the  substance  into  the 
trachea  and  possibly  cause  it  to  become  lodged  in  one  of  the  larger  bronchi. 
And  it  may  be  difficult  to  dislodge  it  from  such  a  point. 

In  the  after-treatment  it  is  wise  to  guard  against  the  irritation  of  the 
lungs  on  account  of  the  effect  which  the  air  has  in  coming  directly  in  con- 
tact with  the  mucous  membrane  of  the  trachea  and  bronchi  without  first 
passing  through  the  nose  and  pharynx.  This  irritation  may  be  avoided  by 
placing  over  the  opening  a  wire  frame  on  which  a  layer  of  gauze  has  been 
stretched,  which  is  kept  moist  with  normal  salt  solution. 

The  tracheotomy  tube  should  consist  of  an  outer  and  inner  tube,  the 
latter  being  changed  frequently  enough  to  prevent  the  accumulation  of 
mucus.  It  is  a  good  rule  to  leave  a  tracheotomy  tube  in  place  as  short 
a  time  as  possible,  because  some  portion  of  the  higher  tube  is  liable  to  do 
injury  to  the  trachea,  and  the  longer  it  is  left  in  place  the  greater  is  the 
likelihood  of  permanent  injury  being  done  to  this  structure. 

INTUBATION. 

Since   the   introduction   of  antitoxin,   intubation   has   been    found  quite 


Fig.  12. 

By  the  courtesy  of  Dr.  George  E.  Brewer,  representing  the  preliminary  tracheoto- 
my with  peritracheal  tamponade  preparatory  to  performing  laryngectomy. 


Fig.  13. 

By  the  courtesy  of  Dr.  George  E.  Brewer,  representing  his  exposure  of  the  larynx 
and  thyroid  membrane  in  his  operation  of  laryngectomy. 


SURGERY    OF    THE    NECK  177 

sufficient  to  relieve  the  obstruction  of  the  larynx  due  to  diphtheria.  It  is 
rarely  necessary  now  to  leave  a  tube  in  place  for  more  than  one  or  two  or, 
at  most,  three  days,  because  the  diphtheritic  membranes  have  usually  disap- 
peared entirely  within  this  time  if  large  doses  of  antitoxin  have  been  given. 

Accompanying  Difficulties  and  Their  Correction. 

The  difficulties  which  accompany  intubation  are : 

ist.  The  danger  of  forcing  portions  of  the  diphtheritic  membrane 
down  into  the  trachea. 

2nd.     The  danger  of  injuring  the  vocal  cords. 

3rd.  The  danger  of  the  patient  coughing  out  the  tube  in  the  absence 
of  the  physician,  and  the  inability  of  the  nurse  to  replace  it. 

4th.  The  difficulty  some  people  have  in  taking  food  in  the  presence 
of  an  intubation  tube. 

5th.  In  rare  cases  the  intubation  tube  will  touch  a  point  in  the  larynx, 
at  the  base  of  the  epiglottis,  which  seems  to  produce  an  immediate  paralysis 
of  the  respiratory  centers,  causing  almost  instant  death  unless  artificial 
respiration  be  performed  until  the  effect  of  this  traumatism  has  passed  away. 

(i.)  The  first  difficulty  must  be  overcome  by  an  immediate  trache- 
otomy ;  consequently  the  surgeon  should  always  be  prepared  to  perform  a 
tracheotomy  before  he  begins  intubation.  This,  however,  becomes  necessary 
only  very  rarely,  but  when  it  does  the  conditions  are  so  urgent  that  unless 
the  surgeon  is  prepared  to  perform  tracheotomy  at  once  the  patient  will 
probably  be  hopelessly  asphyxiated  before  the  necessary  preparations  can 
be  made. 

(2.)  The  second  danger  can  be  avoided  by  great  care  in  performing 
the  operation. 

(3.)  Since  the  introduction  of  antitoxin  we  have  never  seen  a  case  in 
which  the  child  suffered  seriously  from  coughing  out  the  intubation  tube. 
Whenever  this  has  happened  there  has  usually  been  at  the  same  time  a 
loosening  of  a  portion  of  the  membrane  so  that  a  replacement  of  the  tube 
was  not  necessary. 

(4.)  Patients  who  find  difficulty  in  taking  nourishment  can  usually  be 
sustained  very  nicely  if  they  are  placed  in  the  inverted  position  and  per- 
mitted to  take  liquids  through  a  tube. 

The  first  and  most  important  condition  to  be  secured  in  order  to  make 
a  satisfactory  intubation  is  perfect  rest  and  quietude  of  the  patient. 

Technique. 

If  a  patient  is  able  to  move,  even  though  to  a  slight  extent,  it  will  be 
difficult  to  insert  the  tube  without  causing  injury  to  some  of  the  parts.  To 
secure  the  child  so  that  it  cannot  move  it  is  best  to  take  an  ordinary  sheet, 
have  the  child's  arms  placed  alongside  the  body,  and  then  wrap  the  sheet 
around  and  around  a  number  of  times  so  that  the  arms  cannot  be  removed 
from  the  sheet.  In  attempting  to  move  the  arms  the  child  will  pull  both  ways 
at  the  same  time  and  the  result  will  be  that  it  will  not  move  at  all.  The  child 
should  then  be  taken  upon  the  lap  of  an  assistant,  its  head  should  be  held 
against  the  left  shoulder,  the  left  arm  of  the  assistant  should  pass  across 
the  lower  portion  of  the  child's  chest,  while  the  right  arm  should  hold  its 
head  firmly  against  his  shoulder.  In  this  way  the  child  can  be  held  perfectly 
still.  The  gag  is  then  inserted  between  the  teeth  and  held  by  a  second  assistant 
who  stands  behind  the  one  holding  the  child.  The  surgeon  then  inserts  the 


I7  SURGERY    OF   THE    NECK 

first  finger  of  the  left  hand  into  the  mouth,  lifts  the  epiglottis  upwards  and 
holds  it  in  this  position  while  he  carries  the  tube  mounted  upon  the  applicator 
into  the  mouth  arid  along  the  inner  side  of  the  index  finger.  This  will  guide 
it  directly  into  the  larynx.  It  is  pushed  down  into  the  larynx  gently  and  then 
released  from  the  applicator  by  the  mechanism  provided  for  that  purpose. 
At  the  same  time  the  index  finger  is  placed  upon  the  tip  of  the  tube  and  the 
latter  is  driven  down  so  that  the  rim  at  its  upper  end  rests  upon  the  broad 
surface  of  the  vocal  cords.  The  applicator  is  in  the  meantime  withdrawn 
quickly  and  this  will  enable  the  child  to  breathe  through  the  tube. 

It  is  wise  to  leave  a  firm,  silk  thread  attached  to  the  intubation  tube  and 
to  have  this  passed  out  through  the  angle  of  the  mouth  and  fastened  upon 
the  cheek  by  means  of  rubber  adhesive  strips.  In  this  manner  the  removal 
of  the  tube  may  be  accomplished  by  the  nurse  in  case  it  should  become 
occluded  during  the  absence  of  the  surgeon. 

LARYNGOTOMY. 

The  presence  of  a  foreign  body  in  the  larynx  underneath  the  vocal 
cords,  which  cannot  be  forced  out  by  the  efforts  of  the  patient  and  which 
cannot  conveniently  be  reached  through  a  tracheotomy  wound,  sometimes 
necessitates  the  splitting  of  the  larynx.  The  same  operation  is  occasionally 
indicated  in  the  presence  of  benign  growths  located  underneath  the  vocal 
cords. 

The  important  point  in  this  operation  consists  in  the  thorough 
anesthetization  of  the  interior  of  the  larynx  by  means  of  a  spray  of  a  four 
per  cent,  solution  of  cocaine  in  water.  The  patient  is  placed  in  the  Trende- 
lenburg  position  with  the  head  dependent  over  the  end  of  the  table.  An 
incision  is  made  in  the  median  line  extending  from  a  point  an  inch  above 
the  prominence  of  the  thyroid  cartilage  to  a  point  opposite  the  isthmus  of  the 
thyroid  gland.  This  incision  is  carried  down  to  the  larynx,  care  being  taken 
to  grasp  all  of  the  blood  vessels  at  once.  Just  before  opening  the  larynx  the 
cocaine  spray  should  again  be  applied,  it  having  been  thoroughly  applied 
just  before  beginning  the  operation.  Then  a  sharp  tenaculum  is  inserted  on 
each  side  of  the  median  line  and  while  an  assistant  makes  gentle  traction 
upon  these  tenaculre  a  longitudinal  incision  is  made  through  the  larynx.  As 
soon  as  the  larynx  is  opened  there  is  usually  a  violent  attack  of  coughing 
unless  the  part  has  been  thoroughly  cocainized.  If  a  foreign  body  is  lodged 
in  the  larynx  the  first  effort  of  coughing  usually  forces  it  out,  and  the  same 
precaution  should  here  be  taken  that  was  mentioned  in  connection  with 
tracheotomy  for  the  removal  of  foreign  bodies  in  the  trachea.  An  assistant 
should  be  ready  to  sponge  away  any  mucus  that  is  forced  out  by  the  first 
effort  of  coughing,  because  this  is  likely  to  contain  the  foreign  body. 

In  case  the  operation  is  performed  for  the  removal  of  a  growth  the 
larynx  should  again  be  sprayed  with  cocaine  after  it  has  been  opened  in  order 
that  the  operation  may  not  be  interrupted  on  account  of  coughing  due  to  an 
irritation  of  the  mucous  membrane.  The  diseased  portions  may  then  be  so 
perfectly  exposed  that  their  removal  is  not  connected  with  any  difficulty. 
Hemorrhage  is  controlled  in  the  usual  way.  ;md  after  the  operation  has  been 
completed  the  wound  is  closed  by  means  of  deep  and  superficial  sutures. 
The  deep  sutures  should  not  enter  the  larynx. 


SURGERY    OF   THE    NECK  179 

LARYNGECTOMY. 

In  the  presence  of  a  malignant  growth  confined  to  some  portion  of  the 
larynx  its  removal  is  indicated  if  the  surgeon  be  fairly  certain  that  there  has 
been  no  secondary  involvement. 

The  same  preparations  mentioned  in  connection  with  laryngotomy 
should  be  practised  in  laryngectomy.  If  there  has  been  sufficient  obstruction 
to  the  entrance  of  air  for  a  considerable  time  before  the  patient  comes  under 
the  care  of  the  surgeon  to  greatly  reduce  the  strength  of  the  patient  a  pre- 
liminary tracheotomy  should  be  done  so  that  the  general  condition  may  be 
improved  before  the  radical  operation  is  undertaken.  If  the  obstruction  is 
not  sufficient  to  seriously  inter  fere  with  the  patient's  breathing  then  it  is  just 
as  well  to  do  the  operation  at  once  without  having  made  a  preliminary 
tracheotomy. 

The  operation  should  again  be  performed  with  the  patient  in  the  Trende- 
lenburg  position,  with  the  head  dependent  over  the  end  of  the  table  in  order 
to  prevent  the  entrance  of  blood  into  the  trachea. 
Technique. 

An  incision  is  made  from  a  point  an  inch  and  a  half  above  the  prom- 
inence of  the  thyroid  cartilage  to  a  point  just  above  the  sternum.  The 
vessels  overlying  the  larynx  and  trachea  are  carefully  caught  with  hemostatic 
forceps  and  cut.  The  isthmus  of  the  thyroid  is  grasped  between  two  pairs  of 
hemostatic  forceps,  cut  and  ligated.  After  the  larynx  and  trachea  have  been 
carefully  laid  bare  a  tenaculum  may  be  inserted  into  the  third  or  fourth  ring 
of  the  trachea  and  the  latter  cut  transversely.  It  is  then  rapidly  drawn  up 
and  loosened  so  that  its  upper  end  faces  forwards  and  acts  as  a  curved  tube 
communicating  with  the  anterior  surface  of  the  neck.  It  is  dissected  loose 
sufficiently  to  project  half  an  inch  beyond  the  margin  of  the  skin,  which  is 
button-holed  a  short  distance  below  the  lower  end  of  the  incision,  so  that  the 
end  of  the  trachea  may  be  drawn  through.  This  will  aid  in  preventing  the 
discharge  from  the  wound  from  entering  the  trachea  and  causing  aspira- 
tion pneumonia.  It  is  then  sutured  in  place  by  means  of  several  fine  sutures 
which  extend  through  the  third  or  fourth  ring  of  the  trachea.  The  upper 
portion  of  the  skin  incision  is  left  open  to  facilitate  the  remaining  steps  of 
the  operation  necessary  to  remove  the  larynx.  In  this  manner  the  patient 
is  enabled  to  breathe  without  the  danger  of  inspiring  blood.  It  is  also 
possible  by  placing  the  anesthetic  upon  a  piece  of  gauze  held  over  the  end  of 
the  trachea  to  continue  the  anesthesia  without  annoyance. 

The  larynx  is  now  carefully  dissected  out,  beginning  from  below, 
loosening  both  sides  simultaneously  and  controlling  the  hemorrhage  step  by 
step  by  means  of  hemostatic  forceps  and  ligatures.  It  is  well  to  keep  the 
larynx  and  trachea  cocainized  in  order  to  prevent  the  annoyance  due  to 
coughing.  When  the  upper  end  of  the  larynx  is  reached  care  should  be 
taken  to  cut  its  attachment  in  the  pharynx  so  that  the  latter  can  be  closed  by 
means  of  sutures.  If  the  pharynx  is  already  involved  in  the  malignant 
growth  the  removal  of  the  larynx  is  practically  useless  and  a  simple  trache- 
otomy will  be  of  quite  as  much  benefit  to  the  patient ;  consequently  in  cases 
proper  for  the  removal  of  the  larynx  these  flaps  can  be  formed  without  fear 
of  leaving  portions  of  the  carcinoma.  The  pharnyx  is  then  carefully  closed, 
preferably  with  two  rows  of  sutures,  a  piece  of  iodoform  gauze  is  carefully 
tamponed  underneath  the  wall  thus  formed  in  order  to  provide  drainage  in 


l8o  SURGERY    OF    THE    NECK 

case  of  leakage.  The  remaining-  portion  of  the  wound  is  then  carefully 
sutured  by  means  of  deep  and  superficial  sutures. 

It  is  usually  not  necessary  to  insert  a  tracheotomy  tube  in  a  trachea 
which  has  been  brought  out  in  the  manner  just  described.  The  skin  should 
be  carefully  sutured  above  and  below,  and  it  is  well  to  protect  the  wound 
against  infection  from  the  mucus  expelled  from  the  trachea  by  the  applica- 
tion of  some  oily  substance,  such  as  vaseline.  The  dressing  must  neces- 
sarily be  small  in  order  that  the  entrance  to  the  trachea  be  not  obstructed  in 
any  way.  The  same  precaution  should  be  taken  against  irritation  from  the 
direct  introduction  of  air  into  the  trachea  that  was  mentioned  in  connection 
with  tracheotomy.  A  frame  covered  with  gauze  should  be  fastened  over  the 
opening  and  kept  moist  by  the  application  of  a  small  amount  of  normal  salt 
solution.  As  soon  as  the  wound  has  healed  an  artificial  larynx  should  be 
fitted  into  the  trachea.  It  is  claimed  that  a  sufficient  amount  of  air  can  be 
retained  in  the  pharynx  to  give  an  audible  voice  sound,  making  the  use  of 
an  artificial  larynx  unnecessary. 

"We  have  seen  one  case  in  which  the  patient  could  make  all  of  his  wants 
known  with  perfect  ease,  and  could  even  engage  in  conversation.  The 
total  amount  of  air  available  at  any  time  is.  however,  so  slight  that  the 
speech  is  quite  spasmodic. 

DIFFUSE  DISSECTING  LIPOMA  OF  THE  NECK. 

This  usually  begins  in  the  median  line  opposite  the  spurious  processes 
of  the  cervical  vertebrre,  and  becomes  wider  in  every  direction  until  it  covers 
the  entire  posterior  surface  of  the  neck,  giving  the  appearance  from  the  rear 
of  an  enormous  collar  of  fat.  Laterally  it  advances  around  the  neck  until 
its  two  wings  meet,  unless  an  excision  is  made  before  this  occurs.  The 
tumor  is  lobulated,  is  from  i  to  5  cm.  thick,  and  it  has  the  peculiar  quality 
of  following  the  connective  tissue  in  every  direction  by  dissecting  its  way 
between  the  other  structures  and  apparently  consuming  the  connective  tissue 
on  its  way,  hence  the  name  of  dissecting  lipoma.  Its  lobules  will  insinuate 
themselves  between  the  muscle  fibres  of  the  neck,  between  the  lobules  of  the 
parotid  and  thyroid  glands  and,  in  fact,  between  all  of  the  structures  which 
contain  connective  tissue. 

It  causes  much  distress  from  its  weight  and  from  pressure,  and  is 
extremely  unsightly.  The  patients  acquire  an  appearance  which  reminds 
one  of  the  cachexia  in  malignant  disease,  although  milder  in  form. 

As  soon  as  the  diagnosis  has  been  made  the  growth  should  be  excised 
bv  means  of  a  most  painstaking,  exact  dissection,  because  if  any  lobules 
remain  a  recurrence  is  to  be  expected.  In  severe  cases  it  is  best  to  remove 
one-half  of  the  tumor  first  in  order  to  enable  the  patient  to  lie  down  with 
some  degree  of  comfort.  After  the  one  side  has  healed  fully  the  other  may 
be  operated. 

These  surfaces  are  so  large  that  drainage  is  indicated,  otherwise  serum 
is  likely  to  accumulate  under  the  large  flap  and  healing  will  therefore  be 
retarded.  The  drainage  may  be  removed  on  the  second  or  third  day  after 
the  operation. 

THYROGLOSSAL  CYST. 

In  some  cases  the  thyroglossal  duct  has  failed  to  become  obliterated 
during  fetal  life  and  having  a  mucous  lining  it  continues  to  secrete  mucus, 


SURGERY    OF   THE    NECK  l8l 

which  may  be  emptied  either  through  an  opening  at  the  external  end  of  the 
duct  opposite  the  prominence  of  the  thyroid  cartilage,  or  into  the  mouth 
through  its  opening  at  its  inner  end  opposite  the  hyoid  bone,  or  both  ends 
may  discharge  this  mucus,  forming  a  thyroglossal  fistula. 

Again  both  ends  may  be  closed  and  a  thyroglossal  cyst  form.  In  either 
event  the  only  treatment  promising  relief  consists  in  the  complete  excision 
of  every  portion  of  the  mucous  lining. 

This  lining  is  extremely  delicate  and  it  is  possible  to  make  a  complete 
dissection  only  if  the  very  greatest  care  is  exercised.  This  is  true  especially 
because  the  canal  is  frequently  not  straight  and  the  cyst  wall  often  forms 
irregular  pockets.  The  dissection  may  be  facilitated  by  injecting  melted 
paraffin  (melting  point  of  110°  F.)  into  the  sinus  permitting  this  to  harden 
and  then  removing  the  cyst  or  sinus  with  its  paraffin  plug. 

The  outer  opening  is  grasped  with  fine  forceps  and  the  skin  surrounding 
the  osteum  is  excised,  together  with  the  lining  of  the  entire  sinus  or  cyst, 
care  being  taken  to  remain  outside  of  the  cyst  throughout  the  operation. 

ESOPHAGOTOMY. 

Foreign  bodies  frequently  become  lodged  in  the  esophagus  at  a  point 
behind  the  upper  end  of  the  sternum.  Usually  it  is  possible  to  grasp  them 
with  esophagus  forceps  and  remove,  especially  if  they  are  of  material  which 
makes  it  possible  to  locate  them  by  the  use  of  a  flueroscope,  with  the  X-ray 
tube  behind  the  patient  and  the  surgeon  in  front.  We  have  been  able  to  pass 
a  forceps  into  the  esophagus,  to  open  its  jaws  at  the  moment  it  touched  the 
foreign  body,  and  to  grasp  the  body  conveniently  for  removal.  If  this  can 
not  be  done  through  the  mouth  it  may  frequently  be  done  through  an  esoph- 
agotomy  opening. 

Technique. 

An  incision  seven  cm.  long  is  made  along  the  anterior  border  of  the 
lower  end  of  the  sterno-cleido-mastoid  muscle,  the  lower  end  extending  to  a 
point  one  cm.  above  the  clavicle. 

The  skin,  fascia  and  platysma  are  severed.  The  sterno-cleido-mastoid 
muscle  is  retracted  outward  and  the  sterno-thyroid  and  hyoid  muscles  are 
retracted  inward,  the  omohyoid  is  severed,  the  outer  capsule  of  the  thyroid 
gland  is  split  and  the  lobe  of  the  gland  is  retracted  upward.  The  deep 
fascia  is  then  split,  exposing  the  inferior  thyroid  artery,  which  extends 
inwards  and  upwards  across  the  interior  border  of  the  longus  colli  muscle. 
This  vessel  is  clamped  between  two  pair  of  hemostatic  forceps,  cut  and 
ligated.  At  this  point  the  same  care  must  be  exercised  in  protecting  the 
recurrent  laryngeal  nerve  that  was  described  in  thyroidectomy.  It  crosses 
the  inferior  thyroid  artery  in  the  form  of  a  delicate  white  thread-like  struc- 
ture. It  is  well  to  retract  the  nerve  with  a  fine  tenaculum  toward  the  median 
line. 

It  is  important  to  open  the  esophagus  laterally  and  not  anteriorly, 
because  of  the  danger  of  wounding  the  nerve. 

A  large  steel  urethral  sound,  or  an  olive-pointed  esophagus  dilator,  is 
now  inserted  through  the  mouth  and  two  fine-toothed  forceps  are  caught  in 
the  side  of  the  esophagus,  or  the  same  result  may  be  accomplished  by  plac- 
ing two  fine  silk  sutures,  one  cm.  apart,  in  the  side  of  the  esophagus  and 


l82  SURGERY    OF   THE   NECK 

making  a  longitudinal  incision  through  the  wall  half  way  between,  the  two 
sutures  or  forceps  being  used  as  retractors. 

A  large  Jacob's  retention  catheter,  or  a  soft  rubber  tube,  is  inserted  into 
the  esophagus  through  the  wound  and  held  in  place  by  a  suture.  This  tube 
should  extend  at  least  a  distance  of  20  cm.  into  the  esophagus  so  that  liquid 
nourishment  may  be  passed  down  through  it. 

The  wound  is  tamponed  widely  open  with  gauze  and  moist  antiseptic 
dressings  are  applied  and  renewed  every  two  hours,  as  the  discharge 
through  a  fistula  in  the  esophagus  is  likely  to  be  very  offensive. 

If  the  foreign  body  has  not  been  lodged  long  enough  to  cause  infection, 
the  wound  in  the  esophagus  may  be  sutured  at  once  with  catgut,  but  should 
nevertheless  be  kept  widely  open  with  tampons. 

If  the  operation  is  performed  for  the  relief  of  obstruction  of  the  phar- 
ynx or  esophagus  above  this  point  a  permanent  esophageal  tube  may  be  intro- 
duced to  facilitate  the  feeding  of  the  patient,  or  the  edges  of  the  v/ound  in 
the  esophagus  maty  be  sutured  to  the  edges  of  the  skin  wound,  which  will 
enable  the  patient  to  use  a  removable  esophagus  tube  later  on.  In  most 
cases,  however,  the  patient  is  not  likely  to  profit  much  by  this  operation  for 
the  relief  of  obstruction  due  to  carcinoma.  We  have  never  encountered  a 
case  in  which  the  operation  was  necessary  for  the  relief  of  obstruction  due  to 
cicatricial  occlusion,  although  such  cases  are,  of  course,  possible. 


PART    IV. 


SURGERY  OF  THE  CHEST. 

EMPYEMA. 

The  most  common  pathological  condition  of  the  chest  for  which  surgical 
treatment  is  indicated  is  an  accumulation  of  pus  in  the  cavity  thereof, 
the  result  of  an  infection  due  to  the  specific  micro-organisms  present 
in  a  preceding  pneumonia,  or  to  the  infection  of  the  pleura  by  means 
of  the  bacillus  of  tuberculosis,  or  any  one  of  the  pus-producing  micro-or- 
ganisms. The  condition  is  usually  preceded  by  an  inflammation  of  the 
pleura  accompanied  with  serous  effusion  into  the  pleural  cavity,  which 
later  becomes  infected.  This  gives  rise  to  the  formation  of  the  pus  char- 
acterizing the  condition  of  empyema. 

Signs  and  Symptoms. 

There  is  usually  a  history  of  pneumonia  accompanied  by  severe  pleuritic 
pains,  or  a  history  of  apex  tuberculosis.  During  the  accumulation  of  pleu- 
ritic fluid  there  is  shortness  of  breath  and  a  short,  irritable,  hacking  cough. 
If  the  disease  is  due  to  a  tuberculous  infection  an  evening  temperature  is 
likely  to  be  noted ;  if  due  to  an  infection  by  the  pneumococcus  the  tempera- 
ture is  liable  to  be  persistent. 

There  is  a  bulging  of  the  side  of  the  chest  involved ;  upon  percussion 
there  is  dullness  which  varies  with  the  position  of  the  patient,  except  in 
cases  in  which  the  two  layers  of  the  pleura  are  adherent  above  the  em- 
pyema. This  condition  is  usually  not  present  except  in  recent  cases,  hence 
it  is  not  difficult  to  differentiate  between  the  late  stages  of  empyema  and 
hydrothorax  by  physical  examination.  If  the  empyema  is  extensive  there 
is  usually  a  displacement  of  the  heart.  A  good-sized  trocar  inserted  between 
the  ribs  over  the  middle  of  the  area  of  dullness  may  discover  pus,  but  the 
absence  of  pus  should  not  be  considered  as  proof  of  the  non-existence  of  an 
empyema,  because  it  frequently  happens  that  the  pus  is  so  much  thickened 
that  it  cannot  be  withdrawn  even  through  a  large  trocar.  The  trocar  is 
useful  to  differentiate  between  hydrothorax  and  an  empyema,  as  in  the 
former  condition  the  fluid  is  sufficiently  thin  to  be  forced  out  through  the 
instrument.  In  tubercular  empyema  there  is  frequently  much  coagulated 
serum  which  cannot  be  forced  even  through  a  large  trocar. 

Glycerine-Formalin  Solution. 

Murphy  has  demonstrated  that  in  a  large  proportion  of  cases  which 
come  under  treatment  reasonably  early  the  empyema  will  absorb  and  leave 
the  patient  in  an  ideal  condition  if  a  portion  of  the  pus  contained  in  the 
pleural  cavity  is  withdrawn  and  the  following  solution  injected  through  the 
trocar:  viz.,  a  two  per  cent  glycerine  solution  of  formalin  which  contains 


184  SURGERY    OF   THE   CHEST 

forty  per  cent  of  formaldehyde.  It  is  always  kept  ready  for  use  so  that  it  is 
never  necessary  to  use  this  preparation  recently  mixed.  This  is  important  be- 
cause in  the  freshly  prepared  solution  there  are  always  little  globules  of 
formaline  which  will  cauterize  any  surface  with  which  they  come  in  contact, 
while  in  the  mixture  which  has  stood  for  a  number  of  days  the  solution  is  per- 
fect and  this  accident  does  not  occur.  From  ten  to  sixty  c.c.  of  this  solution  is 
injected  into  the  pus  remaining  in  the  chest  cavity  after  a  portion  of  the 
pus  has  been  removed  through  a  trocar  to  which  a  rubber  tube  at  least 
thirty  cm.  long  is  attached  to  prevent  the  patient  from  filling  the  chest 
cavity  with  air  by  some  sudden  inspiration.  The  progress  of  the  case  de- 
termines the  time  at  which  this  treatment  is  to  be  repeated,  and  the  number 
of  repetitions. 

Anesthesia. 

In  the  presence  of  pus  in  the  pleural  cavity  in  cases  not  yielding  to 
the  treatment  just  described,  an  operation  is  always  indicated.  If  the  pa- 
tient's condition  does  not  warrant  the  use  of  a  general  anesthetic  the  opera- 
tion may  be  performed  with  the  use  of  a  one  per  cent,  solution  of  cocaine 
injected  into  the  skin  and  into  the  sheaths  of  intercostal  nerves  a  slight 
distance  above  the  point  at  which  the  operation  is  to  be  done.  The  point 
to  be  chosen  for  the  operation  is  the  middle  of  the  area  of  dullness,  usually 
about  the  sixth  or  seventh  rib. 

Technique. 

An  incision  from  two  to  six  inches  in  length  is  made  parallel  with  the 
rib  in  the  posterior  axillary  line.  A  longitudinal  incision  is  made  through 
the  periosteum  and  this  is  removed  by  means  of  a  periosteal  elevator.  A 
pair  of  bone-cutting  forceps,  or  especially  devised  rib-cutting  forceps  or 
shears,  is  then  carefully  applied  to  the  rib  of  the  posterior  end  of  the  wound ; 
the  rib  is  cut  off,  grasped  by  a  pair  of  bone-holding  forceps  and  lifted 
out  of  its  periosteum  to  the  extent  to  which  its  removal  is  desired.  It  is 
then  cut  off  at  this  point  with  the  bone-cutting  or  rib-cutting  forceps.  The 
periosteum  of  the  rib  and  the  pleura  now  lie  between  the  abscess  and  the 
operator.  If  the  empyema  has  existed  for  a  short  time  only  it  is  not  neces- 
sary to  remove  more  than  one  segment  of  rib,  but  if  it  has  existed  for  a 
considerable  period  it  is  often  wise  to  remove  a  portion  of  two  or  more 
ribs  at  once  in  order  to  insure  a  sufficient  amount  of  space  for  permanent 
drainage,  as  well  as  to  provide  for  a  certain  amount  of  contraction  of  the 
chest  wall. 

Drainage  and  Non-irrigation. 

A  longitudinal  incision  is  now  made  through  the  middle  of  the  perio- 
steum in  order  to  avoid  the  intercostal  vessels  and  nerves.  This  will 
permit  the  pus  to  escape  from  the  pleural  cavity.  It  is  well  to  make 
this  incision  sufficiently  large  for  perfect  drainage.  By  inserting  the  finger 
through  this  opening  one  can  determine  accurately  the  extent  of  the  pus 
cavity.  A  long  pair  of  dressing  forceps  is  now  passed  through  this  opening, 
across  the  cavity  explored,  and  its  end  is  forced  out  between  two  ribs  on 
the  anterior  surface  of  the  chest  wall  at  a  point  suitable  lo  the  conditions 
present.  An  opening  is  cut  down  upon  the  forceps  and  two  perforated 
rubber  drainage  tubes  at  least  half  an  inch  in  diameter  are  drawn  through 
this  opening  into  the  chest  and  out  of  the  original  incision  behind.  They 
are  protected  by  means  of  safety  pins  at  each  end,  and  after  the  pus  lias 


SURGERY    OF   THE   CHEST  185 

been  permitted  to  escape  a  large  dressing  composed  of  aseptic  gauze  and 
absorbent  cotton  is  applied  over  both  openings.  Neither  irrigation  nor 
sponging  is  made  use  of.  This  dressing  is  changed  as  frequently  as  soiled, 
but  irrigation  is  not  practised  at  any  time. 

In  large  accumulations  of  pus  in  the  pleural  cavity,  especially  if  there 
is  a  communication  between  the  abscess  and  a  bronchial  tube,  it  is  often  not 
safe  to  operate  with  the  patient  in  the  recumbent  position.  In  such  a 
case  it  is  best  to  aspirate  most  of  the  pus  through  a  trocar  at  least  two 
mm.  in  diameter  or  to  operate  with  the  patient  in  the  sitting  posture. 

In  these  cases,  furthermore,  the  operation  should  always  be  performed 
with  the  greatest  possible  rapidity. 

After-treatment. 

In  the  after-treatment  it  is  important  in  the  first  place  to  secure  perfect 
drainage,  which  is  insured  in  the  operation  which  has  been  described  from 
the  fact  that  the  drainage  tubes  extend  entirely  across  the  pus  cavity  and 
consequently  when  the  diaphragm  encroaches  upon  this  cavity  from  below 
and  the  lung  from  above  the  through  drainage  persists.  Were  there  but 
one  opening  in  the  chest  wall  a  pocket  might  readily  form  at  some  point, 
but  with  the  precaution  of  having  two  openings  with  drainage  tubes  ex- 
tending from  one  to  the  other  this  cannot  occur. 

It  is  important  to  make  the  dressing  large  enough  to  completely  close 
the  opening  against  the  entrance  of  air  from  without  and  to  insure  this  by 
carefully  applying  bandages  around  the  dressings  to  hold  them  in  the 
desired  position. 

After  the  discharge  has  been  greatly  reduced  it  is  wise  to  begin  giving 
the  patient  systematic  breathing  exercises.  He  should  be  directed  to  inhale 
as  fully  as  possible  through  the  nose,  keeping  the  mouth  closed,  and  then 
to  blow  out  forcibly  through  a  tube  with  an  aperture  of  about  two  milli- 
meters diameter.  These  exercises  should  be  frequently  repeated  during  the 
day.  It  is  well  to  continue  in  this  respect  for  many  months  after  the 
patient  has  recovered,  because  it  will  aid  in  overcoming  the  deformity  which 
is  sure  to  be  present  to  some  extent  after  the  operation. 

Danger  of  Supervening  Tuberculosis. 

Even  in  cases  of  empyema  not  complicated  with  tuberculosis  there  is 
always  a  greater  tendency  to  the  development  of  this  disease  than  in 
normal  lungs ;  consequently  these  patients  should  be  advised  to  live  under 
favorable  hygienic  surroundings  and  they  should  be  given  general  tonics 
whenever  their  condition  of  health  requires.  If  there  is  any  suspicion  of 
the  presence  of  tuberculosis  anti-tubercular  measures  should  be  used  for 
a  long  period  after  recovery  from  the  operation.  If  the  empyema  has 
resulted  from  a  traumatism,  such  as  a  penetrating  wound,  especially  a  gun- 
shot wound  made  with  ordinary  firearms,  the  infection  is  frequently  due  to 
the  fact  that  some  portion  of  clothing  has  been  carried  into  the  pleural 
cavity  and  consequently  it  is  well  in  these  cases  to  make  the  opening  in  the 
posterior  axillary  line  sufficiently  large  to  enable  a  surgeon  to  examine 
the  cavity  for  such  substances. 

Continuance  of  the  Drainage. 

It  is  well  to  leave  the  drainage  tubes  in  place  until  one  is  certain 
that  the  entire  cavity  has  been  closed  down  to  these,  because  if  they  are  left 
in  place  a  little  too  long  no  harm  can  come  from  it,  while  if  they  are  re- 


1 86  SURGERY    OF   THE  CHEST 

moved  too  soon  a  new  pocket  of  pus  may  form,  necessitating  a  secondary 
operation.  If  it  seems  desirable  to  reduce  the  size  of  the  drainage  tube 
it  is  well  to  draw  smaller  tubes  through  the  entire  distance  so  that  the 
through  drainage  is  maintained  as  long  as  drainage  is  made  use  of.  If 
the  granulations  in  the  space  occupied  by  the  drainage  seem  flabby  or 
unhealthy  it  is  good  practice  to  drop  a  small  quantity  of  strong  compound 
tincture  of  iodine  into  the  cavity  in  order  to  produce  a  stimulating  influence. 
Although  these  cases  usually  progress  favorably  occasionally  one  is 
encountered  in  which  healing  is  greatly  retarded,  or  in  which  fistulas  or 
abscesses  have  persisted  for  a  long  time  after  the  original  operation. 

FISTULA  AND  ABSCESSES  FOLLOWING  OPERATIONS  FOR 

EMPYEMA. 

Although  the  relative  proportion  of  persistent  fistulse  and  abscesses 
is  not  so  great  as  formerly  after  operations  for  the  relief  of  empyema  of 
the  chest,  since  surgeons  take  the  same  precautions  as  in  aseptic  cases 
to  prevent  secondary  infection  during  and  after  this  operation,  they  are  still 
sufficiently  common  to  be  a  source  of  much  annoyance  to  the  surgeon. 

There  are,  of  course,  other  elements  of  value  from  the  standpoint 
of  prophylaxis,  aside  from  that  of  aseptic  operation  and  after-treatment. 

The  method  advised  by  Murphy  of  aspiration  and  subsequent  injection 
into  the  pleural  cavity  of  60  cc.  of  a  2  per  cent,  solution  of  formalin  in 
glycerine,  and  the  plan  of  making  tubular  through  drainage  in  case  of 
operation  instead  of  simply  making  drainage  into  the  pleural  cavity,  should 
be  mentioned  especially.  The  former  method  of  treatment  makes  the  latter 
unnecessary  in  many  cases,  and  the  latter  method  reduces  the  number 
of  persistent  fistulse  and  abscesses  to  a  minimum,  because  it  eliminates  the 
formation  of  pockets. 

Beck's  Bismuth  Paste. 

In  cases  in  which  these  sinuses  or  abscesses  persist,  however,  in  which 
formerly  the  method  of  Estlander  and  Schede  gave  the  most  reasonable 
promise  of  ultimate  success,  surgical  treatment  has  often  been  most  dis- 
appointing. It  is  just  in  this  class  of  cases  that  the  method  introduced 
by  Dr.  Emil  Beck  has  given  the  most  satisfactory  results. 

The  method  consists  in  filling  the  sinus  or  pus  cavity  with  a  mixture  of 
bismuth  subnitrate  and  keeping  this  in  position  by  plugging  the  outer  open- 
ing with  gauze.  The  mixture  consists  of  one  part  of  arsenic-free  subnitrate 
of  bismuth  and  two  parts  of  sterile  amber  vaseline. 

This  mixture  is  injected  every  second  day  until  suppuration  has  dis- 
appeared. The  injections  are  repeated  as  often  as  necessary  to  keep  the 
sinus  or  pus  cavity  constantly  filled  with  the  preparation.  At  first  it  is  nec- 
essary to  do  this  every  day  or  every  second  day,  then  every  third  and  so 
on  until  it  may  be  necessary  to  inject  not  oftener  than  once  a  week  or 
ten  days. 

We  have  employed  this  form  of  treatment  in  many  cases  and  it  shows 
results  which  are  much  better  than  those  obtained  previously. 

One  feature  has  been  most  striking.  In  cases  that  were  in  a  septic 
condition  when  the  treatment  was  commenced,  the  improvement  of  the 
general  condition  of  the  patient  was  especially  marked.  Pulse  and  tempera- 
ture became  normal  within  a  few  clays  and  the  general  appearance  of  the 


SURGERY   OF   THE  CHEST  1 87 

patient  lost  the  characteristics  of  sepsis.  The  nutrition  improved  and  the 
anemia  disappeared  rapidly.  The  discharge  from  the  sinuses  usually  becomes 
sterile  in  a  short  time. 

To  illustrate  this  a  short  abstract  of  the  history  of  the  following  case 
will  be  typical. 

An  Illustrative  Case. 

A.  S.,  an  Italian  laborer,  60  years  of  age,  had  a  pneumonia  followed  by 
empyema  of  the  right  thorax  seven  months  ago.  The  pleural  cavity  was 
drained ;  a  sinus  persisted,  leading  into  a  large  cavity.  Three  months  later 
Estlander's  operaton  was  performed  with  excision  of  three  ribs.  The 
patient  was  in  a  severely  septic  and  anemic  condition  when  he  entered  the 
hospital.  An  injection  of  720  cc.  of  the  bismuth  mixture  was  given  and  the 
patient  put  to  bed.  In  two  days  60  cc.  more  was  injected,  but  by  this  time 
the  septic  condition  had  markedly  decreased,  and  within  a  week  the  patient 
became  normal  and  his  anemia  began  to  disappear.  For  one  month  injec- 
tions were  made  every  second  day,  the  quantity  in  the  meantime  decreasing 
to  35  cc.  and  the  patient  acquired  a  rosy  appearance.  Then  he  was  sent 
home, — at  first,  to  return  twice  a  week  to  have  a  few  cc.  injected,  and  later 
only  once  a  week,  a  sufficient  amount  being  used  each  time  to  fill  but  not 
to  distend  the  cavity. 

Nine  months  later  his  general  health  was  perfect  and  there  was  but  a 
superficial  sinus  which  holds  scarcely  5  cc.  of  the  paste,  and  which  would 
undoubtedly  heal  completely  in  a  short  time. 

A  second  case  seems  worthy  of  special  description  because  it  is  one  of 
those  that  were  formerly  extremely  difficult  to  heal. 

History  in  Abstract.- — F.  C.,  American,  age  35,  miner,  had  a  severe  fall 
nine  months  ago  while  working  in  the  mountains ;  this  was  followed  by 
pneumonia  and  then  by  a  right-sided  empyema.  This  was  drained  through 
a  rib  resection  opening.  Seven  months  later  an  Estlander  operation  was 
made,  with  resection  of  three  ribs.  At  the  end  of  two  months  the  patient 
came  under  our  care.  At  this  time  there  was  a  sinus  discharging  pus  freely, 
and  the  patient  coughed  up  the  same  material.  This  was  before  we  were 
familiar  with  the  bismuth  paste  treatment — so  performed  Schade's  operation. 
The  patient  did  well  for  nearly  a  week,  when  he  developed  a  phlebitis  in 
both  femoral  veins.  He  became  markedly  septic  and  emaciated.  Four  weeks 
later  he  still  expectorated  pus,  and  there  was  a  free  drainage  of  pus  from 
the  wound  when  we  began  the  injection  of  No.  I  bismuth  paste.  He  expec- 
torated much  of  the  650  cc.  of  the  paste  injected.  The  injection  was  re- 
peated, each  time  simply  filling  the  cavity  without  using  any  force.  The 
pus  and  sepsis  subsided  rapidly.  In  ten  days  he  appeared  like  a  different 
person,  and  in  twelve  weeks  he  was  perfectly  well. 
Conclusions  and  Further  Details. 

This  treatment  has  proven  most  satisfactory.  We  have  used  it  only  in 
cases  \vith  sinuses,  although  it  has  been  suggested  to  aspirate  the  pus  in 
empyema  and  to  inject  the  paste  into  the  pleural  cavity  through  the  trocar. 

There  has  been  no  case  of  bismuth  poisoning  in  our  series  of  cases, 
although  this  might  easily  occur — as  it  has  when  cavities  in  other  portions  of 
the  body  have  been  filled  with  large  quantities  of  bismuth  paste.  If  this 
occurs,  Beck  advises  the  immediate  injection  of  hot  olive  oil,  110°  F.,  which 
will  dissolve  the  paste  and  facilitate  its  escape  through  the  outer  fistula  or 
through  a  drainage  tube,  which  may  be  inserted. 


i88 


SURGERY    OF   THE   CHEST 


The  injection  is  made  with  a  large,  ordinary  glass  syringe,  just  enough 
force  being  employed  to  fill  the  sinus  or  cavity,  but  not  enough  to  cause 
forcible  distension.  The  outer  opening  is  carefully  plugged  with  sterile 
gauze. 

In  a  few  cases  of  empyema,  accompanied  by  tuberculous  cavities  of  the 
lung,  in  which  the  patient  came  under  treatment  in  a  severely  septic  state, 
with  a  communication  between  the  sinus  and  the  cavity  in  the  lung,  so  that 
the  patient  would  expectorate  the  bismuth  paste  after  injection,  we  have  had 
remarkable  improvement. 

The  paste  seemed  to  result  in  a  disinfection  of  the  sinus  and  cavity  so 
that  the  symptoms  of  acute  sepsis  disappeared,  which  gave  the  patient  an 
opportunity  once  more  to  collect  some  strength  to  withstand  the  tuberculosis. 

CHRONIC  EMPYEMA. 

Conditions  Favoring  This  Disease. 

The  drainage,  followed  by  the  use  of  Beck's  paste,  of  an  empyema  of 
the  chest  does  not  always  result  in  the  complete  cure  of  the  empyema.  This 
may  be  occasioned : 

i st.  By  the  contraction  of  the  lung  to  such  an  extent  as  to  leave  a 
considerable  space  which  is  not  filled  by  re-expansion. 

2nd.     By  the  unyielding  condition  of  the  chest  wall. 

3rd.  By  the  fact  that  there  are  sometimes  a  number  of  abscesses  sep- 
arated from  each  other  by  adhesions  between  the  pulmonary  and  the  costal 
pleurce.  It  happens  occasionally  that  only  one  of  a  number  of  these  abscesses 
is  opened,  and  then  the  drainage  of  that  focus  can,  of  course,  not  relieve  the 
other  abscesses.  Frequently  there  are  small  sinuses  communicating  between 
the  different  pus  formations  so  that  there  is  a  constant  flow  from  an 
undrained  abscess  into  the  drained  one ;  or  this  communication  may  from 
time  to  time  become  obstructed  and  then  the  drained  abscess  will  approach 
complete  healing  only  to  have  a  new  discharge  of  pus  into  it  from  its  un- 
drained neighbor.  In  such  instances  it  is  usually  possible  to  locate  the  other 
abscesses  by  means  of  percussion. 

Again  the  healing  may  be  prevented  because  of  the  inelasticity  of  the 
thickened  pleura  which  prevents  it  from  applying  itself  to  the  surface  of  the 
lung.  It  frequently  happens  that  the  costal  pleura  is  several  centimeters 
in  thickness.  There  may  also  be  a  necrosis  of  one  or  more  ribs  secondary  to 
the  pleuritic  infection,  which  may  again  account  for  the  fact  that  healing 
does  not  take  place.  In  still  other  cases  there  is  a  constant  reinfection  from 
a  tubercular  abscess  in  the  lung  which  perhaps  did  not  directly  communicate 
with  the  empyema  at  the  time  of  the  operation.  All  of  these  conditions, 
with  the  exception  of  the  last  one,  can  be  relieved  by  a  proper  operation, 
which  must  have  in  view  the  application  of  the  chest  wall,  or  what  is  left  of 
it,  to  the  surface  of  the  lung. 

Technique. 

The  operation  to  be  chosen  must  depend  upon  the  extent  and  location  of 
the  empyema.  If  this  is  confined  to  the  lower  portion  of  the  chest  cavity 
an  excision  of  a  number  of  ribs,  beginning  with  the  seventh,  eighth  or  ninth 
and  going  upward  until  the  upper  edge  of  the  empyema  is  reached,  will 
usually  suffice.  The  thickened  pleura  should  be  removed  at  the  same  time. 
The  intercostal  arteries  should  be  ligated  in  this  operation  even  though  no 


SURGERY    OF   THE  CHEST  189 

hemorrhage  takes  place  at  the  time  of  the  operation,  or  they  should  at  least 
be  crushed  with  clamp  forceps  because  they  frequently  begin  to  bleed  after 
the  patient  has  recovered  from  shock,  unless  they  have  been  properly 
disposed  of. 

If  the  empyema  extends  up  to  a  point  above  the  level  of  the  lower  angle 
of  the  scapula  then  it  is  usually  wise  to  make  a  large  flap  of  the  chest 
wall  with  its  base  upward,  cutting  through  the  skin,  the  muscle,  the  ribs  and 
the  pleura,  and  cutting  away  a  sufficient  portion  of  the  rib  ends  to  permit 
this  flap  to  sink  into  the  cavity.  Here  again  the  intercostal  arteries  should 
be  cared  for.  It  is  usually  wise  to  apply  a  large  tampon  composed  of  aseptic 
gauze  to  the  entire  cavity  and  to  lay  the  large  flap  which  has  thus  been 
formed  upon  the  surface  of  this  tampon  and  then  to  apply  a  large  dressing 
over  it.  This  tampon  is  left  in  place  for  a  sufficient  length  of  time  to  stimu- 
late the  growth  of  vigorous  granulation  tissue  over  the  under  surface  of  this 
flap  as  well  as  over  the  surface  at  the  bottom  of  the  cavity.  After  the 
tampon  has  been  removed  the  flap  is  placed  in  this  cavity  and  permitted 
to  heal  in  place.  In  this  operation  again  it  is  often  wise  to  excise  a  thick- 
ened pleura.  If  the  condition  is  due  to  the  presence  of  necrotic  ribs  these 
should  be  removed.  If  it  is  due  to  a  reinfection  from  a  tubercular  lung 
either  of  the  methods  which  have  just  been  described  may  be  used,  but  they 
are  usually  not  followed  by  a  complete  recovery.  Occasionally  it  seems  best 
to  treat  a  chronic  empyema  by  laying  the  cavity  widely  open  by  one  or  the 
other  of  the  methods  just  described,  to  apply  a  large  tampon  to  the  cavity 
thus  exposed  and  to  reduce  this  tampon  slowly  until  the  entire  cavitv  has 
healed  from  the  bottom.  In  chronic  empyema  we  should  say  that  the  most 
important  point  consists  in  making  the  operation  thorough  enough. 

Even  after  this  operation  sinuses  sometimes  persist  and  these  should 
then  be  treated  by  the  injection  of  bismuth  paste  after  the  method  described 
above.  In  our  recent  experience  the  results  have  been  very  good  even  in  the 
cases  which  formerly  appeared  almost  hopeless. 

OPERATIVE   TREATMENT   OF   UNILATERAL   LUNG  TUBERCULOSIS 

BY  TOTAL  MOBILIZATION  OF  THE  CHEST  WALL,  BY  MEANS 

OF   THOROCOPLASTIC    PLEURO-PNEUMOLYSIS. 

The  many  attempts  by  surgical  means  (by  injection,  opening  of  the 
cavity  formed,  or  by  resection  of  the  rib,  and  part  of  the  lung)  to  cure  pul- 
monary tuberculosis  have  proven  very  unsatisfactory  because  the  slow- 
process  of  healing  makes  it  a  relatively  hopeless  process. 

Murphy,  Forlanni  and  Brauer  by  artificial  pneumothorax  caused  com- 
pression of  the  lung  tissue  with  reduction  of  size  of  cavity  and  immobilization 
of  the  affected  lung  tissue. 

Brauer  states  that  adhesions  occur  in  one-fourth  of  all  cases  of 
.pulmonary  tuberculosis,  therefore,  nitrogen,  if  introduced  between  the 
pleurae,  is  an  impossible  procedure  in  a  large  majority  of  cases.  Other  meth- 
ods of  reducing  the  volume  of  the  lung  and  shrinking  of  cavities  in  the  lung 
tissue  have  been  attempted. 

Brauer  advocates  loosening  of  adhesions  by  surgical  interference,  and 
then  reducing  the  volume  of  lung  by  introduction  of  nitrogen  between  the 
layers  of  pleurae.  Friedrich  objects  to  this  method  because  the  pleura 
remains  thin  in  spite  of  adhesions,  and  during  manual  separation  without 
aid  of  sight  there  is  exceedingly  great  danger  of  tearing  the  lung  tissue. 


SURGERY    OF  THE  CHEST 

Also  because  of  the  following  complications:     Empyema  of  the  pleurae, 
mediostinitis,  which  markedly  endanger  the  patient's  life. 

Friedrich  speaks  of  a  case  in  which  there  was  a  large  cavity,  which,  on 
draining  of  mild  serous  pleural  exudate,  became  an  extensive  pleural  sup- 
puration, terminating  fatally  in  a  few  weeks. 

FRIEDRICH'S   METHOD   FOR  MOBILIZATION    OF  CHEST  WALL  BY 
MEANS  OF  TOTAL  REMOVAL  OF  BONE  WITH  PRESER- 
VATION OF  PLEURA  COSTALIS. 

In  young  individuals  the  operation  has  a  tendency  to  produce  marked 
shrinking  of  the  lung  on  the  side  on  which  resection  is  done  and  drawing 
the  opposite  lung,  heart,  mediastinum,  diaphragm  and  clavicular  fossa 
toward  the  shrinking  lung,  which  produces  hindrances  in  the  process  of 
recovery. 

For  this  reason  efforts  should  be  directed  to  prevent  this  tendency  of 
shrinking  of  an  extensively  involved  lung.  This  difficulty  is  overcome  by 
extensive  rib  resection  if  the  chest  cavity  is  allowed  to  be  closed. 

Although  most  patients  have  fever  and  considerable  expectoration,  no 
antipyretics  or  expectorants  are  given,  but  efforts  are  used  to  increase  appe- 
tite and  to  improve  the  gastro-intestinal  functions. 

Confine  patient  to  bed — give  definite  physical  and  X-ray  examination. 

Technique. 

On  day  of  operation,  nothing  by  mouth  except  a  cup  of  tea  in  the 
morning.  Twenty  minutes  before  the  operation  give  hypodermic  of  .015  to 
.02  morphine  muriate. 

After  this  and  before  the  anesthetic  is  commenced  all  possible  expecto- 
ration is  encouraged  for  a  long  time  to  free  the  bronchi  and  caverns  of 
secretion  and  diminish  danger  of  aspiration  during  the  anesthesia. 

Place  the  patient  in  a  semi-oblique  position  with  the  body  turned  half 
over  on  well  side  with  the  arm  held  vertically  up  in  the  air. 

Disinfect  the  surgical  field  very  thoroughly  with  soap,  ether  and 
alcohol. 

Incision  is  made  similar  to  that  in  Schede's  method  of  thoracoplasty  in 
empyema,  the  muscle  being  rendered  analgesic  by  Schleich's  infiltration 
method.  Then  a  flap  is  formed  by  beginning  the  incision  three  fingers' 
breadth  external  to  edge  of  the  sternum  at  the  height  of  second  or  third  rib; 
it  is  carried  downwards  external  to  the  nipple  to  the  tenth  rib,  posteriorly  up 
again  to  the  second  dorsal  spine.  The  line  of  incision  is  varied  occasionally 
for  cosmetic  reasons. 

In  dividing  the  serratus  magnus  muscle  the  ends  of  the  serrations  are 
allowed  to  remain,  otherwise  the  whole  muscle  with  the  vessels  and  nerves 
is  rapidly  displaced  upward.  The  pectoralis  major  and  latissimus  dorsi  are 
deeply  niched  and  drawn  strongly  aside  with  retractors. 

The  bony  chest  is  now  all  exposed.  Then  with  greatest  rapidity  the  ribs 
are  resected,  leaving  periosteum  and  intercostal  muscles  behind,  being,  how- 
ever, all  the  time  careful  not  to  puncture  the  pleura  costalis,  as  a  pneumo- 
thorax  at  the  present  stage  would  greatly  endanger  the  patient,  as  a  marked 
increase  in  secretions  of  the  caverns  would  greatly  promote  suppuration. 
This  accident  is  very  much  more  easily  avoided  by  using  the  positive  or 
negative  air-pressure  apparatus  of  Brauer  or  Sauerbruch. 

After  detachment  of  the  second  to  tenth  ribs  from  the  anterior  carti- 


SURGERY   OF   THE  CHEST  19! 

lages  to  the  spine,  and  especially  after  the  attachments  of  second  and  tenth 
ribs  gives  way,  the  whole  lung  covered  by  the  intact  pleura  costalis  sinks 
back  toward  the  hilus,  and  in  operations  on  the  left  side,  the  heart  can  be 
seen  rising  above  the  level  of  the  lung  surface.  By  practice  such  rib  resec- 
tions as  these — removing  in  all  180  to  220  cm.  of  bone — can  be  done  in 
twenty-five  minutes. 

After  removal  of  projecting  pieces  of  intercostal  muscles,  nerves,  and 
periosteum,  and  careful  hemostasis,  the  flap  of  muscle  is  carefully  approxi- 
mated with  twenty  to  thirty  buried  catgut  sutures.  Skin  sutures  with  silk 
are  applied  and  a  thick  drainage  tube  is  inserted  along  the  spine. 

Little  General  Anesthesia  Required. 

As  a  rule,  if  all  these  conditions  are  carefully  attended  to  during  the 
operation  the  patient  should  have  a  good  pulse  on  leaving  the  table.  Inhala- 
tion anesthesia  is  only  necessary  when  rib  resection  proper  is  commenced, 
provided  morphine  and  infiltration  anesthetic  has  been  previously  used.  The 
anesthetic  is  given  in  restricted  amount  so  that  bronchial  and  laryngeal 
reflexes  remain,  in  order  to  facilitate  expectoration,  while  pain  is  not  felt. 
An  experienced  anesthetist  can  do  this  with  5  to  15  gms.  of  chloroform. 

The  Heart-effect. 

A  mildly  compressing  aseptic  dressing  and  bandage  is  applied  and 
patient  put  to  bed  in  a  prone-oblique  position.  The  most  important  factor 
during  the  following  hours  and  days  is  the  behavior  of  the  heart,  which  on 
account  of  change  in  volume  has  suffered  more  or  less  dislocation  in  position 
and  with  the  collapsed  lung  it  is  subjected  tg  pressure  of  the  air  on  the 
opposite  side. 

The  preservation  of  the  costal  cartilages  is  important  in  preventing 
dislocation  from  acting  too  much  upon  the  heart.  The  disturbance  in  the 
heart  action  is  similar  to  that  found  associated  with  severe  contusion  of  the 
thorax  and  known  as  delirium  cordis,  characterized  by  increased  rate, 
diminution  in  size,  and  absence  of  pulse.  If  the  heart  is  energetically  stimu- 
lated with  digitalis  intraveneously,  caffein  and  camphor  and  normal  salines 
subcutaneously,  the  patient  is  usually  brought  safely  through  the  dangers. 

The  course  of  wound  healing  is  usually  smooth.  In  six  to  ten  days  the 
drainage  tube  is  removed,  and  healing  by  primary  union  is  obtained. 

Dyspnea  is  the  rule  during  the  first  few  days  following  the  operation, 
due  to  the  fact  that  the  lung  on  the  opposite  side  has  to  do  all  the  work 
for  both,  besides  being  interfered  with  by  pressure  of  the  air  on  the  opposite 
lung  and  the  heart.  This  disappears  in  a  few  days. 

As  the  wound  pain  disappears  expectoration  recurs  and  is  facilitated  by 
pressing  the  hand  against  the  immobolized  side,  thus  aiding  the  removal  of 
contents  of  caverns. 

The  temperature  and  amount  of  sputum  fall  rapidly  as  soon  as  expecto- 
ration has  begun. 

In  unilateral  pulmonary  tuberculosis,  fibre-cavernous  in  type,  occurring 
in  young  and  middle-aged  persons,  with  various  degrees  of  fever,  and  in 
which  climatic,  dietetic,  and  medicinal  measures  have  been  of  no  avail  in 
staying  the  progress  of  the  disease,  the  operation  is  indicated. 

The  degree  of  temperature  and  amount  of  sputum  have  no  influence  in 
the  indications. 

(Be  conservative  in  cases  of  multiple  tuberculosis,  especially  if  asso- 
ciated with  intestinal  tuberculosis.) 


IQ2  SURGERY    OF  THE   CHEST 

The  danger  of  the  operation  lies  in  the  increased  demands  upon  the 
heart. 

TUBERCULOSIS  OF  THE  RIBS. 

This  condition  may  occur  primarily  or  secondarily.  In  either  case  it 
results  in  abscess  formation  and  later  on  to  formation  of  sinuses  leading 
down  to  diseased  bone.  It  is  occasionally  possible  to  secure  healing  by 
making  a  free  incision  over  the  middle  of  the  diseased  rib  reflecting  the 
periosteum  and  curetting  away  the  diseased  tissue,  but  usually  nothing  short 
of  excision  of  the  rib  will  suffice. 

ACTINOMYCOSIS. 
The  Positive  Sign. 

In  the  United  States  empyema  caused  by  an  infection  with  the  ray 
fungus  is  not  so  very  uncommon  and  should  constantly  be  borne  in  mind 
as  one  of  the  possibilities,  especially  as  the  treatment  must  be  entirely  dif- 
ferent in  case  actinomycosis  is  present.  This  condition  can  be  recognized  by 
the  presence  of  little  yellowish  flakes  in  discharge  from  the  empyema  which 
contain  the  characteristic  ray  fungus,  easily  demonstrated  by  microscopical 
examination. 

The  Curative  Value  of  K  I.  and  Dosage. 

In  cases  suffering  from  actinomycosis  it  is  important  to  bear  in  mind  the 
fact  that  this  disease  is  curable  by  the  administration  of  very  large  doses  of 
iodide  of  potash.  Small  doses  are  of  little  benefit.  It  seems  necessary  to 
saturate  the  blood  thoroughly  with  this  drug  in  order  to  destroy  the  parasite. 
The  method  which  we  have  found  most  useful  consists  in  the  administration 
of  sixty  to  ninety  grains  of  iodide  of  potash  in  a  glass  of  warm  milk  three 
times  a  day,  preferably  at  6  a.  m.  and  at  2  and  10  p.  m.,  in  order  to  have  the 
periods  eight  hours  apart,  followed  by  a  pint  of  hot  water.  In  this  way  the 
drug  may  be  given  in  these  large  doses  without  causing  any  marked  dis- 
turbance. It  is  vised  for  three  days  in  succession ;  then  the  patient  is 
permitted  to  rest  for  the  same  period  of  time,  when  the  administration  is 
again  repeated.  After  about  six  weeks  of  treatment  these  cases  usually 
recover  perfectly  unless  an  undrained  abscess  be  present.  In  such  event 
some  of  the  parasites  seem  to  remain  where  the  drug  does  not  reach  them 
and  from  that  point  a  reinfection  may  take  place ;  consequently  it  is  wise 
to  repeat  the  treatment  a  number  of  times  after  permitting  the  patient  to  rest 
for  a  month  or  two,  when  he  has  arrived  at  what  is  considered  a  complete 
cure.  This  precaution  is  especially  needful  in  patients  who  live  at  a  distance 
so  that  they  cannotbe  kept  under  observation  conveniently.  We  have  person- 
ally lost  one  patient  because  this  precaution  was  neglected.  In  a  second 
case  in  which  the  disease  was  located  in  the  neck  the  patient  returned  after 
one  year  with  a  recurrence,  complicated  with  an  edema  of  the  larynx  which 
nearly  proved  fatal.  Renewed  treatment  with  ninety  grains  of  potassium 
iodide  again  relieved  the  patient,  who  has  now  been  well  for  eight  years. 
After  being  apparently  well  the  remedy  was  given  for  three  days  each  month 
for  six  months. 

Purity  of  the  Drug. 

It  is  to  be  borne  in  mind  that  small  doses  of  potassium  iodide  are  abso- 
lutely useless  in  the  treatment  of  this  disease,  Furthermore,  it  is  of  the 


SURGERY    OF   THE  CHEST  193 

greatest  importance  to  use  a  preparation  of  potassium  iodide  which  is  abso- 
lutely pure.  Most  of  this  drug-  as  obtained  in  the  market  seems  not  to  be 
perfectly  pure,  and  while  in  my  experience  ninety  grains  can  always  be 
given  when  the  pure  drug  is  used  many  patients  cannot  take  even  much 
smaller  doses  of  the  ordinary  drug. 

ABSCESS  OF  THE  LUNG. 

Physical.  Signs. 

Following  pneumonia  or  an  infection  in  some  other  part  of  the  body, 
such  as  puerperal  infection,  an  abscess  in  the  lung  not  connected  with  the 
pleural  cavity  may  occur.  This  may  communicate  with  a  bronchus  and 
may  evacuate  itself  thereby  from  time  to  time,  or  it  may  remain  circum- 
scribed within  the  lung  tissue.  It  is  relatively  easy  to  recognize  this  condi- 
tion if  the  abscess  cavity  communicates  with  a  bronchus  because  its  filling 
and  emptying  can  be  observed.  If  it  is  near  the  costal  surface  of  the  lung 
it  may  be  recognized  by  percussion,  giving  much  the  same  sound  that  is 
obtained  upon  percussion  over  the  surface  of  the  liver.  If  the  abscess  is  not 
at  the  edge  of  the  lung  resonance  will  be  observed  above,  below  and  to  each 
side  of  it,  giving  the  impression  of  a  circumscribed  space  rilled  with  fluid. 
Its  presence  usually  gives  rise  to  an  abnormal  temperature,  which  frequently 
reaches  104,  105  and  106°  Fahrenheit. 

In  the  more  serious  cases  a  considerable  portion  of  one  lobe,  or  the 
entire  lobe,  may  become  gangrenous  from  the  presence  of  an  infarct. 

One  of  the  larger  vessels  may  be  completely  obstructed  by  a  thrombus  so 
that  a  considerable  portion  of  lung  tissue  becomes  necrotic.  In  these  cases 
there  is  always  a  very  marked  odor  as  soon  as  the  products  of  this  decom- 
posing lung  tissue  are  expectorated.  The  expectorated  material  usually  has 
the  character  of  thin,  sanguineous  pus,  which  is  quite  characteristic. 

Danger  of  Lung  Collapse  and  Its  Prevention. 

The  rational  treatment  must,  of  course,  consist  in  the  evacuation  of 
the  abscess  externally.  There  is,  however,  one  great  danger  in  this  operation 
resulting  from  the  fact  that  in  order  to  approach  the  abscess  the  pleural 
cavity  must  be  opened,  and  if  an  adhesion  does  not  exist  between  the  pul- 
monary and  the  costal  pleura  the  lung  is  likely  to  collapse.  This  condition 
frequently  results  in  the  death  of  the  patient,  and  in  order  to  guard  against  it 
the  surgeon  should  be  prepared  to  inflate  the  lung  through  a  tube  inserted 
into  the  larynx,  constructed  so  that  its  ends  will  fit  tightly  between  the  vocal 
cords.  Its  top  should  be  connected  with  bellows  by  means  of  which  the 
collapsed  lung  may  be  inflated.  The  apparatus  known  as  the  Fell-O'Dwyer 
is  very  simple  and  efficient,  and  this,  or  a  similar  one,  should  always  be  pro- 
cured whenever  the  operation  here  mentioned  is  undertaken. 

Technique. 

A  U-shaped  incision  should  be  made  over  the  area  covering  the  abscess 
and  the  flap  turned  back,  exposing  two  or  three  ribs.  Portions  four  inches 
in  length  of  at  least  two  ribs  should  be  resected  with  great  care,  in  order 
not  to  penetrate  the  costal  pleura  until  sufficient  space  has  been  secured  to 
repair  the  mischief  which  might  occur  from  the  sudden  collapse  of  the  lung. 
After  this  area  has  been  laid  bare  the  portion  of  lung  opposite  may  be 
grasped  by  means  of  fine  volsellum  forceps  through  the  costal  pleura,  or  fine 
stitches  of  catgut  may  be  passed  through  the  costal  pleura  and  the  adjoining 


194  SURGERY    OF   THE   CHEST 

lung  at  several  points,  or  an  apparatus  for  inflating  the  lung  may  be  applied 
and  the  lung  filled  with  air  by  compressing  the  bellows,  and  then  the  costal 
pleura  may  be  opened  and  the  lung  sutured  to  this  opening,  or  it  may  be 
sutured  to  folds  of  iodoform  gauze  which  are  drawn  over  the  edge  in  the 
opening  in  the  costal  pleura  so  that  the  lung  cannot  be  retracted. 

A  method  which  has  been  very  satisfactory  consists  in  suturing  with 
catgut  pieces  of  wet  gauze  to  the  parietal  pleura  and  lung  around  the  edge 
of  the  opening  before  the  pleura  is  opened ;  the  moist  gauze  prevents  the 
entrance  of  air  and  consequently  pneumothorax  cannot  occur.  The  abscess 
is  then  best  entered  by  means  of  the  actual  cautery,  because  the  opening  thus 
made  will  enlarge  when  the  eschar  caused  by  the  burn  becomes  separated. 

Upon  introducing  the  finger  into  this  cavity  bands  will  be  found  to  pass 
through  it  which  the  surgeon  attempts  to  break  down  in  order  to  reduce 
the  entire  space  into  one  cavity.  These  bands  frequently  contain  large  blood 
vessels  and  it  is  consequently  best  to  apply  hemostatic  forceps  to  them  and  to 
cut  between  these.  The  cavity  may  be  drained  by  inserting  a  few  strands  of 
gauze ;  then  the  wound  is  dressed  as  in  the  operation  for  the  relief  of 
empyema. 

In  case  the  abscess  of  the  lung  approaches  the  pleura,  adhesions 
between  the  pulmonary  and  the  costal  pleurae  have  usually  formed  so  that 
there  is  no  danger  from  the  formation  of  pneumothorax,  but  it  is  never 
safe  to  operate  in  these  cases  without  being  prepared  to  find  no  adhesions 
present.  Here  again  a  large  dressing  is  indicated,  and  it  is  wise  not  to 
permit  the  external  wound  to  heal  too  soon  after  the  operation. 

GUNSHOT  AND  STAB  WOUNDS  OF  THE  CHEST. 

In  the  treatment  of  gunshot  or  stab  wounds  of  the  chest  it  is,  first, 
important  to  determine  whether  there  is  dangerous  bleeding  from  the  inter- 
costal vessels  or  from  the  internal  mammary  artery.  The  former  can  easily 
be  exposed,  clamped  and  ligated.  The  latter,  being  located  near  the  sternum 
between  the  costal  cartilages  and  the  pleura,  is  in  a  position  in  which  it  is 
difficult  to  ligate  without  fear  of  causing  pneumothorax  by  opening  the 
pleura.  The  fact  that  this  vessel  is  given  off  from  the  subclavian  artery 
makes  the  hemorrhage  very  formidable,  and  the  further  fact  that  it  is 
located  behind  the  costal  cartilages  makes  a  hemorrhage  into  the  pleural 
cavity  more  likely  than  an  external  hemorrhage.  In  case  of  bleeding  from 
the  internal  mammary  artery  it  is  necessary  to  remember  that  the  costal 
cartilage  can  be  easilv  cut  with  an  ordinary  scalpel  and  that  the  external 
wound  is  of  no  importance,  consequently  a  large  external  wound  should  be 
made  over  the  costal  cartilage  of  the  next  rib  above  the  point  of  injun,  this 
cartilage  should  be  carefully  cut  away  for  a  distance  of  at  least  an  inch  over 
the  point  at  which  it  crosses  the  artery,  and  then  a  fine  stitch  should  be 
passed  around  the  artery  and  tied.  The  danger  from  trying  to  perform  this 
operation  through  a  small  external  wound  is  very  much  greater  than  it  is 
if  ample  space  be  secured  by  making  a  large  one. 

The  hemorrhage  from  these  two  sources  having  been  disposed  of  the 
next  important  point  is  to  secure,  as  nearly  as  possible,  complete  rest  of  the 
chest  walls.  This  can  best  be  accomplished  by  applying  a  plaster-of-Paris 
jacket  extending  from  the  lower  border  of  the  ribs  up  over  both  shoulders. 
The  patient  will  immediately  begin  to  breathe  by  using  the  diaphragm  alone 
and  the  irritable  hacking  cough  will  in  most  cases  subside,  and  therefore  the 


SURGERY    OF   THE   CHEST  195 

patient  will  stop  pumping  blood  from  the  lung  tissue  into  his  pleural  cavity. 
If  empyema  follows  through  an  infection  caused  by  the  injury  it  should 
be  treated  according  to  the  method  which  has  already  been  detailed. 

Do  Not  Probe:    Apply  Chest  Splint. 

This  point  should  be  borne  in  mind  above  all  things — that  under  no 
condition  should  a  wound  of  the  thorax  be  examined  with  a  probe,  because 
probing  is  one  of  the  chief  sources  of  infection.  If  plaster-of- Paris  is  not 
available,  or  if  the  patient  does  not  seem  sufficiently  strong  to  bear  its 
application,  a  protecting  cast  may  be  constructed  in  a  few  minutes  by  wind- 
ing long  strips  of  rubber  adhesive  plaster,  from  two  to  three  inches  in  width, 
about  the  entire  chest,  beginning  at  the  border  of  the  ribs  and  working 
upwards  until  the  whole  chest  and  shoulders  are  covered.  Several  layers  of 
this  plaster  may  be  applied  to  advantage.  It  is  surprising  how  quickly  a 
patient  who  has  not  been  able  to  rest  for  a  moment  on  account  of  the 
irritation  due  to  the  motion  of  his  chest  walls,  will  become  quiet  and  fall 
asleep  after  one  or  the  other  of  these  jackets  has  been  applied.  Cases  which 
have  so  far  advanced  that  the  danger  of  new  hemorrhage  is  over,  but  in 
which  the  blood  in  the  pleural  cavity  is  not  absorbed,  should  be  aspirated 
through  a  trocar  or  drained  by  open  incision  or  treated  like  an  empyema. 

Value  of  the  Chest  Splint. 

The  same  treatment  with  rubber  adhesive  plaster  strips  acts  quite  as 
beneficially  in  patients  with  severe  injury  to  the  ribs  due  to  contusion.  A 
man  sixty-two  years  of  age  was  caught  under  an  upturned  vehicle  and  rolled 
between  the  ground  and  the  vehicle,  resulting  in  a  number  of  ribs  being 
broken  at  various  places,  ^'hcn  we  saw  him  at  his  home  twelve  hours  later 
his  pulse  was  imperceptible,  he  was  severely  cyanosed  and  only  with  great 
difficulty  could  he  gasp  for  a  little  air.  He  was  almost  unconscious  from 
exhaustion  although  his  head  had  not  been  injured.  As  soon  as  the  rubber 
adhesive  plaster  cast  had  been  applied  the  patient  began  to  breathe  regularly 
and  quietly,  although,  of  course,  entirely  with  his  diaphragm ;  his  pulse 
came  back,  beating  180  per  minute.  Within  an  hour  it  had  been  reduced 
below  100  per  minute.  He  became  perfectly  conscious  at  once  and  made  a 
thorough  recovery.  \\e  have  seen  many  similar  though  less  severe  cases. 

PNEUMOTHORAX. 

If  the  wound  in  the  chest  wall  has  been  sufficient  to  admit  a  quantity 
of  air  the  lung  will  become  compressed  and  a  pneumothorax  will  be  formed. 
All  that  is  required  for  the  relief  of  this  condition  is  the  closure  of  the 
external  wound,  unless  there  has  been  a  complete  collapse  of  the  lung,  in 
which  event  the  lung  should  first  be  distended  by  means  of  inflation  before 
the  opening  in  the  chest  wall  is  closed,  or  the  opening  may  be  closed  and 
the  air  contained  in  the  chest  cavity  may  be  aspirated  by  a  pump  through  a 
trocar.  If,  however,  air  is  forced  into  the  pleural  cavity  from  the  lung  itself 
by  the  injury  of  the  lung  tissue  then  it  may  become  necessary  to  make  a  rib 
resection,  to  grasp  the  injured  point  of  the  lung  with  forceps  to  draw  it  to 
the  external  wound  and  there  to  attach  it,  after  the  manner  described  in  the 
operation  for  abscess  of  the  lung.  The  wound  in  the  lung,  however,  is 
usually  so  small  that  it  closes  spontaneously,  or  it  is  so  large  that  the  patient 
succumbs  before  the  surgeon  has  an  opportunity  to  secure  relief  by  an 
operation. 


196  SURGERY    OF   THE  CHEST 

The  Fell  Bellows. 

Dr.  George  Fell  has  invented  a  form  of  negative  pressure  bellows 
attached  to  a  bell  which  can  be  placed  over  the  opening  in  the  chest  wall  and 
by  means  of  which  a  vacuum  may  be  secured  which  will  immediately  remove 
any  air  that  has  entered  the  chest  cavity  through  an  opening  in  the  chest 
wall.  This  vacuum  can  be  maintained  indefinitely  until  the  wound  in  the 
chest  wall  has  closed  spontaneously,  or  sutures  may  be  inserted  before  the 
airpump  has  been  applied,  and  when  all  of  the  air  has  been  withdrawn  from 
the  pleural  cavity  these  sutures  are  drawn  tense  and  then  tied,  thus  per- 
manently closing  the  chest  cavity  against  recurrence  of  pneumothorax. 

The  Sauerbruch  Cabinet  and  Other  Methods. 

Many  other  forms  of  apparatus  have  been  invented  during  the  past  few 
years  for  the  purpose  of  controlling  especially  that  form  of  pneumothorax 
that  is  produced  intentionally  during  operations  upon  intrathoracic  organs. 
This  idea  was  brought  forward  successfully  and  effectively  first  by  Sauer- 
bruch, who  introduced  a  negative  pressure  cabinet  in  which  the  surgeon  and 
the  body  of  the  patient  was  placed  while  the  patient's  head  projected  into 
the  outer  air  through  an  opening  lined  with  a  perforated  rubber  sheet, 
the  perforation  fitting  snugly  about  the  patient's  neck.  By  pumping  air  out 
of  the  chamber  containing  the  body  a  sufficient  negative  difference  of 
pressure  could  be  produced  to  cause  the  air  which  entered  the  lungs  through 
the  trachea  at  a  higher  pressure  to  distend  the  lungs  to  a  sufficient  extent  to 
prevent  the  formation  of  pneumothorax  when  the  chest  wall  was  opened. 
The  degree  of  pressure  can  be  accurately  controlled  by  an  assistant. 

Brewer  produced  the  same  effect  by  overpressure  by  leaving  the  body 
of  the  patient  in  the  atmosphere  of  the  operating  room  and  placing  the 
head  in  a  cabinet  into  which  air  is  being  pumped  in  sufficient  quantity  to 
produce  a  sufficient  degree  of  pressure  to  prevent  the  formation  of  pneumo- 
thorax when  the  chest  wall  is  opened.  Robinson  has  perfected  a  most 
excellent  apparatus  for  the  same  purpose,  in  which  the  cabinet  containing  the 
high  pressure  air  is  sufficiently  large  to  accommodate  the  anesthetist  at  the 
same  time.  Willy  Meyer  has  produced  a  still  more  ingenious  apparatus  that 
can  be  changed  from  a  negative  to  a  positive  pressure,  and  vice  versa,  in  a 
moment. 

All  of  these  forms,  however,  are  extremely  expensive  and  complicated 
and  only  available  in  large  institutions. 

The  same  overpressure  effect  has  been  produced  by  Fell  with  an  ex- 
tremely simple  mechanism  that  may  be  obtained  at  a  very  small  cost  and 
which  has  been  used  in  a  large  number  of  cases  with  absolutely  satisfactory 
results.  It  consists  of  a  compound  bellows  furnishing  a  uniform  stream 
of  air  which  is  forced  into  the  lungs  through  an  accurately  fitting  mask 
applied  over  nose  and  mouth,  or  through  an  intubation  or  a  tracheotomy 
tube.  Melzer  and  Carrell  have  produced  the  same  result  by  pumping  air  into 
the  lungs  with  ordinary  bellows  through  a  catheter  filling  the  trachea  to  two- 
thirds  of  its  size  and  extending  almost  but  not  quite  to  the  bifurcation  of 
the  trachea. 

We  have  seen  all  of  these  methods  in  use  but  have  used  only  the  Fell 
apparatus  in  our  own  practice  and  its  simplicity  and  effectiveness  has  im- 
pressed us  strongly  in  its  favor.  Theoretically,  however,  there  seems  to  be 
no  doubt  but  that  the  apparatus  of  Willy  Meyer  is  at  the  present  time  the 
most  perfect  for  the  control  of  pneumothorax  during  intrathoracic 
operations. 


SURGERY    OF   THE  CHEST  197 

The  chest  wall  in  all  of  these  cases  must  of  course  be  definitely  closed 
before  the  apparatus  is  discarded  after  any  of  these  operations. 

HYDROTHORAX. 

Hydrothorax  is  so  easily  recognized  by  physical  examination  that  it  is 
scarcely  worth  while  to  discuss  it.  It  is  so  common  in  its  occurrence  that 
it  rarely  reaches  the  hands  of  the  surgeon.  The  accumulation  of  fluid  in  the 
pleural  cavity  may  absorb  spontaneously  or  it  may  be  withdrawn  by  aspira- 
tion. Only  a  part  of  the  fluid  should  be  withdrawn  at  one  time.  '  Many 
authorities  prefer  to  withdraw  but  a  few  ounces  and  to  depend  upon  absorp- 
tion for  the  removal  of  the  remaining  portion,  which  usually  occurs  after  a 
few  ounces  have  been  aspirated.  Other  surgeons  prefer  to  remove  a  consid- 
erable proportion  of  the  fluid.  There  is  no  doubt  but  that  it  is  wise  never  to 
remove  the  entire  amount  present. 

TUMORS  OF  THE  CHEST. 

Of  tumors  of  the  chest  which  are  interesting  in  a  sugical  way  only  those 
due  to  the  presence  of  hydatids,  actinomyces  and  syphilis,  and  dermoid 
cysts,  need  to  be  mentioned.  Sarcomata,  carcinomata  and  endotheliomata 
occur  but  are  not  interesting  surgically  (i.  e.,  call  for  no  particularly  different 
form  of  treatment)  except  from  a  diagnostic  standpoint.  Hydatid  cysts 
most  frequently  occur  through  perforation  of  the  diaphragm  on  account  of 
infection  from  hydatids  of  the  liver.  This  condition  is  treated  in  the  same 
manner  as  empyema.  Actinomycosis  has  already  been  discussed.  Gummata 
are  treated  by  means  of  internal  medication  if  the  condition  is  recognized. 
Dermoid  cysts  are  enucleated,  the  same  precautions  being  taken  to  prevent 
collapse  of  the  lung  that  were  described  in  connection  with  the  treatment  of 
abscess  of  the  lung. 

Lympho-sarcomata  are  of  especial  interest  because  their  usual  location 
about  the  diaphragm  makes  the  differentiation  between  this  condition  and 
empyema  difficult  at  times. 

MEDIASTINAL  ABSCESS. 

This  affection  is  recognized  by  the  symptoms  of  weight  and  pain  in  the 
retro-sternal  region.  The  pain  is  increased  especially  upon  drinking,  cough- 
ing, and  upon  pressure.  There  is  frequently  a  swelling  over  the  surface  of 
the  sternum.  The  condition  is  treated,  when  diagnosed,  after  the  same 
manner  as  abscesses  in  general.  An  opening  is  cut  in  the  sternum  and  the 
pus  permitted  to  evacute.  The  cavity  is  then  drained  by  means  of  strands 
of  gauze  carried  to  the  bottom  of  the  abscess. 

TUBERCULOSIS  OF  THE  STERNUM. 

The  sternum  may  be  removed  in  part  or  entirely  for  tuberculosis,  pre- 
cisely as  one  would  remove  a  tuberculous  rib.  If  possible  the  costal  attach- 
ment should  not  be  disturbed.  The  operation  is  not  especially  dangerous 
because  there  is  in  these  cases  a  sufficient  support  on  account  of  the  pres- 
ence of  connective  tissue  which  has  formed  behind  the  sternum  as  a  result  of 
the  long-continued  inflammation  which  preceded  the  destruction  of  this 
bone. 


198  SURGERY    OF   THE   CHEST 

INFECTIONS  OF  THE  MAMMARY  GLAND. 
Methods  of  Production. 

These  occur  most  commonly  through  abrasions  of  the  nipple  during 
nursing.  The  mouth  of  the  child  may  contain  the  infectious  micro-organisms 
or  they  may  be  upon  the  surface  of  the  nipple  when  the  child  is  applied,  or 
fissures  may  occur  and  the  staphylococci  which  are  ordinarily  found  in  the 
skin  may  cause  the  infection.  The  arrangement  of  the  lymph  channels  and 
milk  ducts,  and  the  connective  tissue  structure  of  the  breast,  radiating  in 
every  direction  from  the  nipple  as  a  center,  account  for  an  infection  follow- 
ing one  or  more  of  these  structures  and  becoming  localized  at  a  smaller 
or  greater  distance  from  the  nipple.  It  may  then  progress  to  the  formation 
of  abscesses  varying  in  size  and  location. 

Upon  examination  one  or  more  points  of  induration  are  commonly 
found.  The  tissues  over  these  points  are  edematous  and  there  is  pain  upon 
pressure.  If  the  infection  is  advanced  there  is  also  redness  or  fluctuation 
present.  The  acuteness  of  the  attack  will  differentiate  this  condition  from 
tumors. 

Aside  from  the  history  of  lactation  there  may  also  be  one  of  trau- 
matism,  or  there  may  be  evidences  of  an  infection  in  some  other  portion  of 
the  body. 

Rest  and  Methods  of  Prevention. 

Early  in  the  occurrence  of  an  infection  of  the  breast  it  is  frequently 
possible  to  cause  it  to  subside  by  securing  absolute  rest.  The  blood  supply 
of  this  portion  of  the  body  is  so  plentiful  that  an  extensive  amount  of  in- 
fectious material  may  be  entirely  absorbed  if  the  progress  of  the  infection 
is  not  favored  by  motion.  The  patient  should  therefore  be  placed  in  bed 
c-nd  the  breast  supported  by  strapping,  preferably  with  rubber  adhesive 
straps  that  have  been  carefully  applied,  or  with  an  accurately  applied  flannel 
or  elastic  rubber  bandage.  If  the  infection  is  quite  slight  then  a  large,  moist, 
antiseptic  dressing  covered  with  rubber  protective  tissue  will,  probably  best 
favor  absorption,  the  patient  of  course  being  kept  at  rest.  Further  infection 
should  be  prevented  by  thoroughly  washing  the  nipples  before  and  after  each 
nursing  and  by  applying  some  antiseptic  substance,  such  as  ointment  contain- 
ing boric  acid  or  some  substance  like  tincture  of  benzoin  or  tincture  of 
myrrh,  which  has  a  protective  effect  on  account  of  its  resinous  character. 
Solutions  of  rubber  have  been  prepared  which  may  be  applied  to  the  nipple 
after  it  has  been  carefully  dried,  and  which  will  serve  as  an  excellent  pro- 
tective covering.  Above  all  things  the  nipples  should  be  kept  clean  at  all 
times  and  should  be  carefully  washed  just  before  and  just  after  nursing. 
The  child's  mouth  should  also  be  washed  in  order  to  prevent  infection  from 
this  source.  The  milk  should  be  pumped  out  of  such  a  breast  at  regular 
intervals,  care  being  taken  not  to  cause  any  traumatism  of  the  infected 
tissues  by  the  manipulations  which  are  thus  necessitated. 

Technique. 

If  the  infection  progresses  to  the  formation  of  circumscribed  abcesses 
these  should  be  incised  freely  and  drained  by  the  insertion  of  gauze  or  gutta 
percha  tissue  drains  and  a  sufficiently  large  dressing  should  be  applied 
to  absorb  all  of  the  discharge.  Personally,  we  prefer  a  moist  antiseptic  dress- 
ing consisting  of  one  part  of  alcohol  with  two  parts  of  saturated  solution 
of  boric  acid  for  this  purpose. 


PLATE  IV. 

AMPUTATION   OF   BKKAST. 

The   incision   extends   in   front   of  the  .axillary   space  and    includes   a  considerable 
amount  of  skin  overlvinar  the  mammarv  trland. 


SURGERY   OF   THE  CHEST  2OI 

It  is  important  that  the  incisions  should  be  made  in  a  manner  so  as  to 
cause  them  to  radiate  from  the  nipple  in  order  to  prevent  cutting  off  any 
of  the  ducts  which  branch  from  this  point.  Rest  in  bed  and  support  by 
means  of  dressings  and  bandages  should  be  insisted  upon,  because  this  will 
prevent  any  formation  of  further  abcesses  by  progressive  infection  after  the 
primary  focus  has  once  been  opened. 

CHRONIC  MASTITIS. 

Chronic  Mastitis  is  the  result  of  a  deep-seated  infection  with  pus 
microbes  of  moderate  virulence.  This  condition  may  give  rise  to  the  diag- 
nosis of  tumor  of  the  breast. 

The  application  of  a  large  glass  bell  attached  to  an  air-pump,  according 
to  Bier's  method,  once  each  day  over  a  breast  which  has  been  incised  for  the 
relief  of  abscess  greatly  facilitates  the  patient's  recovery.  The  negative  pres- 
sure must,  of  course,  be  carefully  regulated  to  prevent  unnecessary  pain. 

In  protracted  cases  that  come  under  the  care  of  a  surgeon  a  long  time 
after  the  abscess  has  been  lanced,  so  that  only  a  sinus  is  left,  we  have  had 
satisfactory  results  by  applying  Bier's  vacuum  pump  and  later  injecting  the 
sinus  with  Beck's  bismuth  paste. 

TUMORS  OF  THE  BREAST. 

Dangers  of  Even  Simple  Growths. 

The  most  common  benign  tumor  in  the  breast  is  the  nbro-adenoma. 
Pure  fibromata  and  pure  adenomata  are  exceedingly  rare.  Aside  from  these 
are  found  retention  cysts,  lipomata,  enchrondromata,  and,  very  rarely, 
hydatid  cysts.  All  of  these  tumors  are  likely  to  occur  in  young  patients. 
They  are  movable  and  are  not  accompanied  with  retraction  of  the  nipple. 
They  give  rise  to  no  pain  and  rarely  grow  to  any  considerable  size.  We  have, 
however,  observed  a  large  number  of  cases  in  which  such  tumors  remained 
perfectly  harmless  until  the  patient's  age  exceeded  forty  years,  when  the 
condition  changed,  at  first  usually  so  slowly  that  the  patient  hardly  was 
aware  of  the  alterations,  then  definite,  stinging  pains  were  felt  and  later  a 
slight  degree  of  induration.  The  history  would  then  show  that  when  the 
patient  came  under  observation  it  was  plain  from  the  external  examina- 
tion that  we  had  to  do  at  best  with  an  adeno-carcinoma,  although  in  these 
cases  of  long  standing  there  could  be  no  doubt  but  that  they  had  started 
as  perfectly  benign  growths.  We  have  encountered  many  of  these  which 
were  hopelessly  advanced  inoperable  carcinomata  when  they  came. 

Accepting  the  general  statement  that  there  is  a  tendency  in  all  tumors 
of  the  breast,  with  the  exception  of  lipomata,  to  become  malignant  later  in 
life,  it  consequently  seems  wise  to  remove  every  benign  tumor  in  this  loca- 
tion as  early  as  possible  after  it  has  been  discovered.  The  operation  is  safe, 
does  not  inconvenience  the  patient,  and  may  relieve  her  of  a  very  serious 
danger.  The  incision  should  be  made  as  much  as  possible  in  the  direction 
indicated  in  the  previous  operation. 

Carcinomata  are  the  most  common  of  all  malignant  tumors  of  the 
breast.  Epitheliomata  are  less  frequent ;  sarcomata  still  less  frequent  in 
their  occurrence.  Paget's  nipple,  which  is  a  dermatitis  with  a  tendency  to 
the  development  of  epithelioma,  is  not  very  common  in  this  country. 

Physical  Signs. 

Heredity  is   supposed  to  be   an   important   element   in   the  history  of 


2O2  SURGERY    OF   THE  CHEST 

malignant  tumors  of  the  breast.  The  growth  itself  may  have  existed  in  the 
form  of  a  benign  tumor  for  a  considerable  period  of  time  (as  has  just  been 
pointed  out),  or  it  may  appear  in  the  form  in  which  it  persists.  Its  location 
is  more  commonly  directly  underneath  the  nipple,  but  it  may  occur  in  any 
portion  of  the  breast.  At  first  it  is  movable,  but  later  it  becomes  adherent  to 
the  skin  or  to  the  fascia  of  the  pectoralis  major  muscle.  One  of  the  signs 
which  has  been  recognized  as  characteristic  is  the  retraction  of  the  nipple 
due  to  the  contraction  of  the  underlying  trabeculse  of  the  connective  tissue. 
This  condition,  however,  is  present  only  if  the  tumor  is  near  the  nipple.  If 
the  growth  is  slow  the  tumor  is  hard ;  if  it  is  rapid  it  may  be  either  soft  or 
hard  upon  pressure. 

Sooner  or  later  the  disease  progresses  along  the  lymph  channels,  form- 
ing secondary  nodules  in  the  lymph  glands,  first  in  the  axillary  region, 
second,  in  the  infra-clavicular  and  later  in  the  supra-clavicular  region.  Still 
later,  lymph  channels  extending  toward  the  skin  are  invaded  and  the  latter 
is  presently  destroyed,  giving  rise  to  an  open  ulcer. 

A  Dangerous  Custom. 

At  this  point  we  wish  to  state  emphatically  that  observations  have  con- 
vinced us  that  an  enormous  amount  of  harm  is  done  to  patients  suffering 
from  incipient  carcinoma  of  the  breast  by  the  careless  manipulation  of  this 
organ  by  the  physician  or  surgeon  making  the  examination,  or  by  any  other 
persons  handling  the  part.  We  believe  that  many  times  we  have  seen  the 
growth  of  carcinoma  of  the  breast  largely  increased  in  this  manner.  We 
believe  also  that  we  have  observed  cases  in  which  secondary  infection  of  the 
lymphatics,  and  even  of  the  liver,  was  caused  by  frequent  manipulation. 
During  the  past  fewr  years  we  have  encountered  a  number  of  patients  suffer- 
ing from  this  disease  who  were  treated  by  severe  massage  at  the  hands  of 
osteopathic  healers,  in  whom  there  was  an  enormous  increase  in  the  growth 
of  the  tumor  in  a  relatively  short  time,  and  in  several  cases  a  secondary  in- 
fection of  the  liver.  In  the  same  manner  an  infection  with  carcinoma  may 
extend  into  the  chest,  following  the  Ipmphatics  which  accompany  the  internal 
mammary  artery ;  or  the  opposite  breast  may  be  invaded  because  of  the 
lymphatic  connection  between  the  two  organs ;  or  it  may  extend  along  the 
intercostal  lymphatics  into  the  spine,  giving  rise  to  paraplegia  dolorosa. 

If  there  is  any  doubt  as  regards  the  diagnosis  of  carcinoma  of  the 
breast  we  believe  that  in  every  case  it  is  much  better  for  the  patient  to  have 
the  organ  removed  at  once,  and  with  the  same  care  that  would  be  exercised 
if  its  malignancy  were  positively  known,  rather  than  to  temporize  until  the 
condition  becomes  so  plain  that  the  surgical  treatment  is  usually  useless  and 
the  patient  therefore  in  a  hopeless  state. 

Age  Incidence. 

Carcinoma  containing  an  abundance  of  connective  tissue  is  more  likely 
to  occur  in  those  advanced  in  years  and  the  malignancy  of  this  form  is  not 
so  great  as  that  in  carcinoma  with  but  a  slight  amount  of  connective  tissue. 
The  latter  form  of  carcinoma  is  more  likely  to  occur  in  young  persons,  usual- 
ly under  fourteen  years  of  age.  Sarcoma  is  also  more  prone  to  occur  at  this 
age,  while  epithelioma,  starting  in  the  skin  and  penetrating  the  deeper  tis- 
sues, is  more  apt  to  develop  in  patients  over  forty  years  of  age;  but  it  is  not 
safe  to  depend  upon  the  age  in  making  a  differential  diagnosis  between  be- 
nign and  malignant  tumors  of  tlie  breast. 

To  differentiate  between  chronic  mastitis  and  tumors,  it  will  be  found 


PLATE  V. 

Outline  of  Incision,  Marked  with  a  Scratch  Stroke  of  the  Knife. 
(Jabez  Jackson.) 


PLATE  VI 

Exposure    and    Division    of    the    Pectoralis    Major. 
(Jabez  Jackson.") 


PLATE  VII. 
Isolation  and   Division  of  the   Pectoralis   Major.      (Jabez  Jackson.) 


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PLATE   IX. 
Method  of   Insertion  of   Figure-of-eight   Coaptation   Sutures.      (Jabez  Jackson.) 


PLATE  X. 
Flap   Sutured   in   Place,   with  Drainage  Tube  Inserted.      (Jabez  Jackson.) 


PLATE  XI. 

AMPUTATION  OF  BREAST  FOR  CARCINOMA. 

a   cut   end   of   pectoralis   major   muscle;    b   cut   end   of   pectoralis    minor   muscle. 
c  brachial  plexus  of  nerves;   e  axillary  vein. 


PLATE  XII. 

AMPUTATION  OF  BREAST  FOR  CARCINOMA. 
The  wound  has  been  sutured  and  drainage  tubes  are  in  place. 


SURGERY    OF    THE    CHEST  215 

that  when  the  breast  is  pressed  against  the  chest  wall  with  the  hand  in 
mastitis  the  enlargement  is  of  uniform  consistency,  in  tumors  there  is  a 
nodular  arrangement  of  the  thickening. 

Operative  Principles. 

There  are  a  few  important  principles  which  should  be  remembered  in 
the  removal  of  a  carcinoma  of  the  breast : 

ist.  The  direction  in  which  carcinomatous  infection  progresses  from 
the  primary  seat  of  disease,  and  consequently  the  direction  in  which  recur- 
rence is  likely  to  take  place,  should  be  noted.  Bearing  this  in  mind,  it  is 
important  to  remove  a  large  portion  of  skin  overlying  the  tumor,  as  shown 
in  Plate  .IV,  even  though  the  tumor  itself  be  quite  small. 

2nd.     The  subcutaneous  fat  should  be  removed  for  a  great  distance. 

3rd.  All  the  tissues  to  be  removed  should  be  included  in  a  continuous 
mass  to  prevent  the  infection  of  any  portion,  during  the  progress  of  the 
operation,  from  an  exposed  part  of  the  malignant  growth. 

4th.  All  the  soft  tissues  down  to  the  ribs,  to  a  point  up  under  the 
clavicle,  as  far  as  possible  into  the  axilla,  including  the  overlying  skin,  the 
superficial  and  deep  fascia,  the  fat,  the  entire  breast  enclosed  in  its  capsule, 
the  pectoralis  major  and  minor  muscles,  and  all  the  axillary  and  subclavian 
fat,  together  with  the  lymphatic  glands  contained  in  it,  should  be  removed 
in  one  mass. 

5th.     The  patient  must  be  protected  against  too  great  a  loss  of  blood. 

6th.  The  important  subclavian  and  axillary  vessels  and  the  pleura 
must  not  be  injured. 

Lines  of  Incision  and  Technique. 

Many  incisions  have  been  planned  and  for  each  certain  advantages  are 
claimed.  It  is  probably  of  little  importance  which  is  chosen.  A  very  good 
exposure  may  be  obtained  by  making  a  curved  wound  beginning  at  a  point 
four  inches  below  the  axilla  along  the  anterior  surface  of  the  deltoid 
muscle,  extending  across  the  chest  at  a  sufficient  distance  from  the  tumor  to 
insure  safety  against  infection,  usually  a  distance  of  six  to  ten  centimeters 
from  the  nipple  will  suffice,  then  carrying  this  incision  around  the  breast  at 
a  uniform  distance  from  the  nipple  and  extending  upwards  to  the  original 
point,  as  shown  in  Plate  IV.  The  most  satisfactory  incision  for  the  re- 
moval of  extensive  carcinomata  in  our  experience  is  the  one  introduced  by 
[abez  Jackson,  as  shown  in  Plate  Y,  because  it  secures  at  once  the  com- 
plete removal  of  all  the  infected  skin,  secures  a  free  approach  to  the  dis- 
eased tissue  as  shown  in  Plates  VI,  VII  and  VIII,  and  provides  for  the 
perfect  closure  of  the  wound  as  shown  in  Plates  IX  and  X. 

After  grasping  the  bleeding  vessels  with  pressure  forceps  the  skin 
around  the  edge  of  this  incision  should  be  dissected  up,  the  underlying  fat 
being  left  attached  to  the  chest  wall.  This  dissection  should  be  carried  a 
sufficient  distance  back  to  include  all  the  diseased  tissue,  at  least  five  centi- 
meters in  each  direction  in  ordinary  cases.  The  incision  is  then  carried 
down  to  the  ribs  along  the  border  of  this  area  and  the  entire  mass,  as  de- 
scribed before,  is  dissected  up  to  a  point  approaching  the  axillary  vein,  care 
being  always  taken  to  grasp  the  bleeding  vessels  with  pressure  forceps. 
Then  the  attachment  of  the  pectoralis  major  to  the  humerus  is  severed  and, 
later,  the  upper  attachment  of  the  pectoralis  minor  is  also  divided.  Between 
these  two  attachments  it  is  wise  to  grasp  the  vessels  with  two  pairs  of 
forceps,  to  cut  between  these  and  to  ligate  the  stump  toward  the  axillary 


2l6  SURGERY    OF   THE   CHEST 

side.  The  disal  ends  of  the  subclavian  and  axillary  veins  are  now  dissected 
free,  all  the  small  branches  issuing  from  the  veins  being  caught  in  two  pairs 
of  hemostatic  forceps.  Cut  between,  and  ligate  the  end  toward  the  axillary 
vein  close  for  fear  of  tearing  the  latter  with  the  forceps.  By  proceeding 
slowly  with  this  portion  of  the  work  it  is  possible  in  a  comparatively  short 
time  to  lay  bare  the  entire  vein  without  doing  any  harm  to  this  structure. 
The  dissection  is  then  carried  downward  through  the  axillary  space,  and 
the  entire  mass  cut  away  from  its  posterior  attachment,  the  bleeding  points 
having  been  caught  carefully  during  each  step  of  the  operation  so  that  the 
entire  amount  of  blood  lost  will  be  slight. 

It  is  important  that  the  tumor  be  not  manipulated  roughly  because  it 
seems  likely  that  carcinomatous  cells  could  be  loosened  from  the  substance 
of  the  growth  if  careless  handling  or  pressure  be  allowed. 

If  there  still  remain  small  portions  of  fat  attached  to  the  axillary 
structures  they  can  be  removed  with  great  rapidity  and  perfect  safety  by 
grasping  them  in  a  piece  of  moist  gauze  held  in  the  hand  and  drawing  this 
gauze  over  these  structures,  permitting  them  to  slip  through  the  grasp  of  the 
hand  holding  the  gauze.  In  this  manner  these  small  portions  of  fat  contain- 
ing minute  lymphatic  glands  may  be  removed  more  perfectly  and  with  much 
greater  ease  and  rapidity  than  by  actual  dissection.  All  the  bleeding  vessels 
that  have  been  caught,  from  which  bleeding  has  not  been  stopped  per- 
manently by  the  pressure  of  the  hemostatic  forceps,  should  be  ligated. 
Personally  we  make  use  of  fine  catgut  for  this  purpose. 

The  area  exposed  is  so  enormous  that  a  certain  amount  of  serous  dis- 
charge must  be  expected,  and  consequently  we  believe  it  is  wise  to  insert  one 
or  two  moderate-sized  drainage  tubes  through  an  opening  in  the  posterior 
flap,  as  shown  in  Plate  XII.  The  wound  is  then  united  by  means  of  inter- 
rupted tension  sutures,  for  which  silk  or  silk-worn  gut  may  be  employed,  and 
coaptation  sutures  for  the  purpose  of  adjusting  the  edges  of  the  wound.  If 
these  edges  cannot  be  adjusted  without  applying  a  great  amount  of  tension 
it  is  much  better  to  leave  a  space  between  the  edges  of  the  wound  and  to 
cover  this  by  means  of  Thiersch's  skin  grafts. 

A  large  dressing  is  applied  to  the  breast  in  order  to  approximate  the 
skin  flaps  to  the  chest  wall  by  means  of  gentle  pressure.  The  arm,  to  the 
elbow,  is  included  in  the  bandage,  but  should  not  be  tied  down  sufficiently 
firm  to  make  the  patient  uncomfortable. 

DISSEMINATED  LENTICULATE  CARCINOMA  OF  THE  SKIN  OF  THE 
BREAST.     (CANCER  EN  CUIRASSE.) 

This  form  occurs  not  infrequently  as  a  direct  cancerous  infection  of 
the  lymphatics  of  the  skin  alter  an  operation  for  the  removal  of  primary 
carcinoma  of  the  breast.  The  infection  may  also  occur  directly  from  the 
primary  carcinoma. 

The  French  name,  indicating  the  appearance  of  a  coat  of  mail,  is  so 
characteristic  that  one  can  scarcely  fail  in  making  the  diagnosis.  Near 
the  region  of  this  complication  the  skin  is  thickly  studded  with  nodules, 
usually  red  in  color,  and  radiating  from  this  area  to  a  considerable  distance 
will  lie  found  smaller  lenticular  nodules.  A  few  times  we  have  observed  this 
form  of  secondary  carcinoma  originating  in  the  stitch  mark,  indicating  that 
the  carcinomatous  tissue  was  directly  inoculated  in  the  skin  from  the  deeper 
portions.  It  is  likely  that  the  subcutaneous  fat  contained  the  carcinoma  cells 


SURGERY    OF   THE   CHEST  21 7 

in  these  instances  and  that  these  cells  were  carried  by  the  needle  into  the 
overlying  lymphatics  of  the  skin  proper. 

The  surgical  treatment  must  be  entirely  prophylactic.  By  removing 
a  large  portion  of  the  overlying  skin,  together  with  the  carcinoma  of  the 
breast,  it  is  likely  that  this  complication  will  be  prevented. 

During  the  past  few  years  a  number  of  these  apparently  hopeless  cases 
have  recovered  after  the  use  of  the  Roentgen  rays.  Whether  such  recovery 
is  to  be  permanent  or  temporary  remains  to  be  seen.  In  our  own  experience 
no  patient  has  ever  presented  herself  for  treatment  of  this  condition  to  whom 
we  could  promise  any  surgical  relief.  Whether  the  excision  of  a  large  por- 
tion of  skin  and  underlying  fat  would  give  relief  in  cases  coming  under 
treatment  very  early  we  are  unable  to  state. 

EPITHELIOMA  OF  THE  BREAST. 

Primary  epithelioma  of  the  nipple  is  not  very  uncommon.  Its  progress 
is  likely  to  occur  more  rapidly  into  the  deep  structures  than  into  the  sur- 
rounding skin.  Even  at  a  very  early  stage  there  has  usually  been  a  second- 
ary infection  of  the  tissues  of  the  breast  itself.  In  a  few  instances  in  which 
the  disease  seemed  to  be  very  limited  we  have  found  that  there  was  an  infec- 
tion not  only  of  the  tissues  of  the  breast,  but  also  of  the  axillary  lymphatic 
glands. 

The  conditions  just  described  will  of  course  indicate  that  the  same  plan 
of  treatment  must  be  followed  which  has  been  outlined  in  connection  with 
carcinoma  of  the  breast  proper.  If  anything  less  is  done  the  progress  of  the 
disease  will  only  be  increased  and  the  patient  is  likely  to  succumb  sooner  than 
she  would  if  nothing  at  all  were  done  in  a  surgical  way ;  in  fact,  with  a  thor- 
ough removal  of  the  skin,  the  breast,  the  pectoralis  major  and  minor  muscles 
and  the  axillary  and  subclavian  lymphatics  and  fat,  these  patients  have  a 
chance  to  recover  permanently. 

SARCOMA  OF  THE  BREAST. 

The  diagnosis  of  sarcoma  of  the  breast  can  usually  not  be  made  posi- 
tively until  the  tumor  has  been  removed.  This  is  of  little  importance  inas- 
much as  the  same  operation  must  be  performed  which  would  be  clone  in  the 
presence  of  a  carcinoma. 

TUBERCULOSIS  OF  THE  BREAST. 

Patients  suffering  from  tuberculosis  of  the  breast  usually  give  a  history 
of  tuberculosis  in  some  other  portion  of  the  body,  most  commonly  pul- 
monary. 

In  many  cases  there  is  the  history  of  an  injury ;  in  others  the  history  of 
localized  tuberculosis  of  the  lymph  glands  in  other  portions  of  the  body. 
The  history,  together  with  the  general  appearance,  of  the  patient  and  the 
fact  that  the  axillary  glands  are  usually  enlarged,  while  the  examination  of 
the  breast  itself  gives  the  impression  one  obtains  in  manipulating  a  chronic 
mastitis  or  a  multiple  nbro-adenoma,  usually  suffices  to  make  a  fairly  positive 
diagnosis  of  tuberculosis.  There  are,  however,  cases  in  which  it  is  not 
possible  to  differentiate  this  condition  from  carcinoma.  If  the  disease  has 
existed  for  a  more  or  less  extended  period  of  time  some  portion  of  the 
growth  will  have  usually  undergone  caseous  degeneration,  giving  rise  to 


2l8  SURGERY    OF   THE  CHEST 

the  sensation  of  fluctuation,  which  will  also  serve  as  a  diagnostic  sign.    The 
nipple  is  usually  retracted. 

The  treatment  should  consist  in  the  removal  of  the  entire  breast,  to- 
gether with  the  lymphatic  glands  and  fat  of  the  axilla.  It  is  not  necessary 
here  to  disturb  the  pectoralis  major  or  minor,  or  the  fascia  covering  the 
former.  Unless  there  is  present  a  mixed  infection  of  some  broken  down 
portion  of  the  tumor  it  is  usually  safe  to  close  the  entire  wound  without 
drainage. 

MILK  FISTULA. 

Following  an  incision  into  the  breast  for  the  drainage  of  an  abscess,  or 
following  the  spontaneous  opening  of  an  abscess  of  the  breast,  and  occa- 
sionally following  traumatism,  a  fistula  remains  connected  with  one  of  the 
milk  ducts  which  secretes  milk  either  constantly  or  intermittently. 

In  recent  cases  these  fistulas  can  sometimes  be  cured  by  cauterizing  the 
external  opening,  or  by  curetting  the  fistula,  or  by  making  a  longitudinal  in- 
cision through  the  fistula,  but  in  chronic  cases  a  careful  excision  of  the 
false  passage  is  necessary  in  order  to  secure  permanent  relief. 

MOBILIZING  THE  CHEST  WALL  FOR  RELIEF  OF  PERICARDIAL 

ADHESIONS. 

Pericardial  adhesions  to  the  chest  wall  cause  a  condition  which  is  at 
once  most  distressing  to  the  patient  and  exhausting  to  the  heart  itself,  as 
with  each  contraction  the  heart  makes  an  unsuccessful  effort  to  pull  itself 
away  from  its  fibrous  attachment  to  the  chest  wall,  and  with  each  expansion 
it  is  pushed  by  the  adhesion  against  this  rigid  wall. 

Mobilizing  this  rigid  wall  then  over  the  area  occupied  by  the  heart  must 
necessarily  bring  great  comfort  to  the  patient  and  must  at  the  same  time 
reduce  greatly  the  wear  and  tear  upon  the  heart  itself.  This  may  be  accom- 
plished by  the  following  operation : 

Technique. 

A  curved  incision  is  made  just  below  the  left  mammary  gland  from 
fifteen  to  twenty  cm.  long;  the  breast  is  reflected  upward  and  the  fourth, 
fifth  and  sixth  ribs  are  laid  bare.  The  middle  of  the  area  to  which  the 
pericardium  is  adherent  is  determined  by  the  impact  of  the  heart  and 
each  rib  is  excised  to  the  length  of  twelve  cm.  so  that  a  vertical  line  drawn 
through  the  center  of  the  area  of  impact  would  bisect  each  fragment  of  rib 
removed. 

In  making  this  excision  if  possible  all  of  the  periosteum  should  be  re- 
moved with  the  ribs,  so  as  to  prevent  their  regeneration. 

The  skin  and  muscle  flap  is  then  replaced,  two  small  gutta  percha  tissue 
or  fine  rubber  tube  drains  are  inserted,  and  the  wound  is  closed. 

The  relief  is  almost  instantaneous  because  the  soft  wall  which  takes 
the  place  of  the  rigid  costal  wall  yields  readily  with  the  motion  of  the  heart, 
whose  pulsation  consequently  becomes  slower  with  an  improved  character 
and  quality  of  the  contraction,  and  a  rapid  building  up  of  the  patient's 
general  condition. 

PERICARDIAL  EFFUSION. 

While  this  can  hardly  be  classed  as  a  surgical  disease,  yet  the  surgeon 


SURGERY    OF   THE  CHEST 

is  often  called  upon  for  relief  when  it  has  become  distressing,  and  so  it 
may  be  proper  to  contribute  a  few  words  to  the  subject  at  this  point. 

The  heart  is  usually  sufficiently  far  away  from  the  chest  wall,  because 
of  the  presence  of  a  large  amount  of  pericardial  fluid,  to  prevent  injury 
when  the  trocar  is  inserted  for  the  purpose  of  partial  withdrawal  of  fluid. 

The  puncture  should  be  made  in  the  fifth  or  sixth  intercostal  space  in 
the  left  mammillary  line  in  large  accumulations,  which  are  the  only  ones 
that  require  this  operation. 

It  is  best  to  use  a  trocar  two  mm.  thick  with  a  very  sharp  but  short 
pointed  stillette.  The  distance  to  which  this  is  to  be  plunged  into  the  chest 
must  be  determined  by  holding  the  point  of  the  index  finger  against  the 
trocar  so  that  it  cannot  be  forced  in  any  farther  than  contemplated.  The 
stillette  is  then  withdrawn  and  enough  fluid  is  permitted  to  escape  to  give 
immediate  relief,  but  not  enough  to  shock  the  patient  or  to  permit  the  heart 
to  touch  the  pericardium. 

The  fluid  should  be  withdrawn  very  slowly,  with  repeated  interruptions, 
especially  if  there  is  any  irregularity  in  breathing  or  in  the  heart's  action 
during  the  progress  of  the  operation. 

The  canula  should  be  held  in  such  a  direction  that  there  is  no  danger 
of  the  surface  of  the  heart  striking  against  it  and  becoming  lacerated.  The 
withdrawal  of  a  portion  of  the  fluid,  usually  from  one  to  four  ounces,  is 
likely  to  stimulate  absorption  of  the  remaining  portion,  but  if  this  does  not 
occur  the  operation  must  be  repeated  whenever  a  sufficient  amount  has  re- 
accumulated  to  give  rise  to  much  distress. 

In  introducing  the  trocar  the  intercostal  vessels  should  be  avoided  by 
remaining  near  the  upper  margin  of  the  rib,  below  the  puncture  point,  and 
avoiding  the  lower  edge  of  the  upper  rib.  The  fourth,  fifth  or  sixth  inter- 
costal space  should  be  chosen,  according  to  the  position  of  the  fluid. 

PERICARDIAL  SUPPURATION. 

The  condition  just  described  may  be  followed  by  suppuration  in  the 
pericardial  space.  In  this  event  it  seems  reasonable  to  expect  that  the  two 
per  cent  formaline  in  glycerine  treatment  introduced  by  Murphy  for  the 
cure  of  empyema  of  the  chest  should  give  satisfactory  results. 

We  have  not  yet  had  an  opportunity  to  test  this  method. 

Simple  aspiration  without  free  drainage  has  given  such  absolutely 
unsatisfactory  results  that  this  should  never  be  practised,  and  in  case  of 
diagnosis  of  pericardial  effusion  and  demonstration  of  the  presence  of  peri- 
cardial suppuration  upon  aspiration  the  radical  operation  should  be  done  at 
once. 

The  operation  for  the  relief  of  this  condition  consists  in  the  removal  of 
ten  cm.  of  the  fourth  or  fifth  rib  over  the  most  prominent  portion  of  the 
pus  sac,  placing  gauze  into  this  wound  for  24  to  48  hours  and  then  making 
a  crucial  incision  through  the  middle  of  the  exposed  area  the  pus  is  per- 
mitted to  drain  through  a  pledget  of  gauze  or  one  composed  of  folded 
rubber  tissue. 

We  have  not  had  an  opportunity  to  use  Beck's  bismuth  paste  in  these 
cases  in  the  after-treatment,  but  it  seems  plainly  indicated  where  healing 
does  not  take  place  promptly  after  drainage  has  been  installed. 

In  cases  wherever  the  intercostal  tissues  are  edematous  at  the  time  of 
the  operation  it  is  not  necessary  to  postpone  the  incision  if  the  patient's  con- 


22O  SURGERY    OF   THE   CHEST 

dition  is  such  as  to  make  an  immediate  evacuation  of  the  pus  desirable,  be- 
cause there  is  no  danger  in  these  cases  from  the  occurrence  of  hydrothorax, 
owing  to  the  fact  that  the  existing  inflammatory  process  has  produced  the 
necessary  adhesions  to  prevent  this. 

WOUNDS  OF  THE  HEART. 

It  is  important  to  be  familiar  with  some  method  of  exposing  the  heart 
in  case  one  should  encounter  a  patient  suffering  from  a  stab  or  gunshot 
wound  thereof.  We  have  never  had  an  opportunity  to  operate  in  one  of  these 
cases  and  consequently  cannot  speak  from  personal  experience  with  any 
method,  but  the  subject  is  so  important  and  any  surgeon  is  so  likely  to  be  in 
a  position  in  which  he  must  act  promptly,  that  we  will  give  the  method 
advocated  by  Kocher  because  it  has  the  advantage  of  great  simplicity  and 
at  the  same  time  fills  all  of  the  demands  met  by  any  or  all  of  the  many  more 
complicated  methods.  It  secures  an  easy,  rapid  approach  to  the  heart, 
gives  an  excellent  exposure  of  the  organ  and  guards  against  the  formation 
of  pneumothorax. 

In  hospital  practice  this  should  further  be  guarded  against  by  the  use 
of  one  of  the  various  devices  that  have  already  been  described ;  but  most  of 
these  patients  are  so  seriously  injured  that  the  time  necessary  to  adjust  an 
apparatus  would  probably  be  sufficient  to  permit  the  patient  to  die  from 
hemorrhage  unless  the  Fell  or  the  Melzer  type  happened  to  be  available. 

The  entire  chest  should  be  quickly  saturated  with  compound  tincture  of 
iodine,  which  should  always  be  at  hand.  The  surgeon  should  put  on  sterile 
rubber  gloves  without  stopping  to  scrub  his  hands. 

If  no  tincture  of  iodine  is  available  the  skin  should  be  scrubbed  rapidly 
with  warm  water  and  soap  with  a  piece  of  gauze,  then  with  alcohol,  then 
ether. 

An  incision  ten  cm.  long  is  made  from  the  middle  of  the  sternum  over 
the  sixth  costal  cartilage  to  the  bony  part  of  the  sixth  rib,  cutting  the  attach- 
ment of  the  rectus  abdominis  muscle.  The  pectoralis  major  is  loosened  from 
its  attachment  to  the  upper  border  of  the  rib  and  the  attachment  of  the  inter- 
costal muscles  is  loosened  both  above  and  below  with  the  knife.  The 
perichondrium  on  the  posterior  surface  is  loosened  with  a  periosteal  elevator. 
The  sixth  costal  cartilage  is  now  cut  at  the  point  of  its  attachment  to  the 
sternum  and  that  to  the  seventh  costal  cartilage. 

The  internal  mammary  artery  and  vein  are  seen  at  a  point  one  cm.  to  the 
left  of  the  sternum ;  they  are  clamped,  cut  and  ligated. 

Underneath  this  point  the  sternal  attachment  of  the  transverse  thoracic 
muscle  is  cut,  and  the  muscle,  together  with  the  pleura,  is  pushed  to  the 
left,  which  exposes  the  dense  fibrous  pericardium. 

If  the  heart  is  compressed  by  the  accumulation  of  blood  in  the  peri- 
cardium this  sac  is  opened  at  once,  otherwise  the  following  steps  are  taken : 

If  the  wound  is  in  the  upper  portion  of  the  heart  the  incision  is  carried 
upward  to  the  fourth,  third  or  second  intercostal  space.  Here  a  lateral 
incision  is  made  eight  cm.  long  through  the  pectoralis  major  muscle  to  the 
upper  margin  of  the  costal  cartilage  and  rib.  The  intercostal  muscle  is 
loosened  from  its  attachment  to  the  upper  margin  of  this  cartilage  and  rib. 
The  pleura,  together  with  the  transverse  thoracic  muscle,  is  now  separated 
from  the  cartilages  and  ribs  and  shoved  to  the  left  and  a  sufficient  amount 
of  the  ribs,  together  with  the  cartileges,  is  cut  away  to  provide  the  necessary 


SURGERY    OF   THE   CHEST  221 

space  for  the  completion  of  the  operation,  which  exposes  the  heart  from  apex 
to  base.  In  case  of  injury  to  the  pleura  the  opening  is  at  once  caught  with 
clamps  and  later  ligated  or  sutured  with  catgut. 

It  is  not  always  necessary  to  make  so  complete  an  exposure  of  the  heart 
because  the  wound  may  present  itself  at  a  point  where  the  heart  is  first 
observed.  In  this  case  it  is  of  course  only  necessary  to  close  the  wound 
at  once  and  the  operation  can  be  completed  without  making  so  extensive 
a  wound.  On  the  other  hand  even  this  extensive  exposure  may  not  be 
sufficient  when  the  right  ventricle  has  been  injured,  in  which  case  it  is  best 
to  cut  off  the  sternum  transversely  with  bone-cutting  forceps  and  turn  it  out 
of  the  way  to  the  right.  But  it  is  only  rarely  necessary  to  make  so  complete 
an  exposure  of  the  heart. 

The  heart  is  grasped  with  two  fingers  of  the  left  hand  and  the  first 
suture  inserted  one  cm.  beyond  one  end  of  the  wound.  The  end  of  the 
suture  is  left  long  and  held  by  means  of  hemostatic  forceps  to  facilitate  the 
completion  of  a  continuous  suture.  Fine  silk  or  fine  very  reliable 
chromicized  catgut  should  be  used  for  suturing  a  heart  wound. 

The  pericardium  and  the  pleura  are  sutured  with  catgut  at  once  without 
drainage.  The  flap  is  then  replaced  and  sutured  and  two  small  drains  in- 
serted to  prevent  accumulation  of  serum  from  the  large  wound  surface. 

It  is  important  to  perform  the  entire  operation  with  the  very  greatest 
precautions  against  infection,  for  this  is  practically  certain  to  destroy  the 
life  of  the  patient  in  even  the  most  hopeful  cases  if  it  occurs. 

Transfusion  of  normal  salt  solution  is  indicated  after  the  operation ; 
and  if  possible  transfusion  of  human  blood  by  the  method  introduced  by 
Crile  would  undoubtedly  be  beneficial. 

EXCISION  OF   COSTAL  CARTILAGES  FOR  RELIEF  OF  EMPHYSEMA. 

This  operation  has  been  strongly  recommended  because  it  reduces  the 
size  of  the  chest  and  thus  permits  the  emphysematous  portions  of  the  lung 
to  contract.  We  have  not  done  this  operation  for  this  particular  purpose  and 
cannot  therefore  speak  authoritatively  concerning  its  beneficial  effects,  which, 
however,  seem  reasonable.  The  same  operation  we  have  performed  fre- 
quently for  the  removal  of  diseased  cartilages.  It  is  simple  and  with  reason- 
able care  it  is  perfectly  safe. 

An  incision  is  made  along  one  border  of  the  sternum,  from  five  to  seven 
cm.  from  its  center,  and  extending  from  the  clavicle  to  the  lower  border  of 
the  ribs.  The  soft  tissues  are  reflected  inward  and  outward  and  each  car- 
tilage is  exposed  successively.  With  a  sharp,  heavy  cartilage  knife  the  car- 
tilages are  cut  off  successively,  then  each  cut  end  is  elevated  with  a  curved 
periostome  and  from  one-half  to  three  cm.  of  the  cartilage  is  removed,  the 
shorter  excision  being  made  at  the  upper  ribs.  The  wound  is  then  closed 
and  dressed  and  a  circular  bandage  of  wide  rubber  adhesive  strips,  extend- 
ing entirely  around  the  chest,  is  applied  the  same  as  in  the  treatment  of  gun- 
shot or  stab  wounds  of  the  chest.  The  other  side  is  treated  in  the  same  man- 
ner as  soon  as  the  patient's  condition  warrants  a  second  operation,  which 
should,  however,  not  be  performed  too  soon. 

FOREIGN   BODIES   LODGED   IN   THE   BRONCHI. 

The  most  common  foreign  bodies  encountered  in  the  bronchi  are  small 


222  SURGERY    OF  THE   CHEST 

objects  which  children  hold  in  their  mouths  while  playing,  like  kernels  of 
corn,  peanuts,  beans,  tacks,  pins,  parts  of  playthings,  etc. 

If  these  are  of  metal  or  any  other  substance  that  will  throw  a  shadow 
when  the  chest  is  exposed  to  the  X-ray,  so  as  to  be  seen  through  a  fluoro- 
scope,  the  object  can  sometimes  be  grasped  with  proper  forceps  and  removed 
under  guidance  of  the  X-ray  shadow. 

Light  objects  like  kernels  of  corn,  beans,  small  buttons,  etc.,  will  usually 
be  coughed  out  of  the  tracheotomy  opening,  if  trachotomy  is  performed 
with  a  dependent  head,  the  patient  being  placed  in  the  Trendelenburg  posi- 
tion with  the  foot  of  the  table  elevated  to  about  forty-five  degrees. 

Of  course  this  will  occur  only  if  the  object  is  not  impacted,  or  has  not 
been  fastened  by  the  occurrence  of  edema.  If  the  object  has  become  fixed 
its  location  may  usually  be  determined  by  auscultation,  as  no  air  passes  be- 
yond the  location  of  the  foreign  body.  In  these  cases  a  low  tracheotomy 
should  be  made  and  a  forceps  should  be  carried  down  the  trachea  into  the 
bronchus  and  down  the  bronchus  until  it  touches  the  foreign  substance,  then 
the  jaws  of  the  instrument  should  be  opened  and  the  object  grasped  if  pos- 
sible. 

At  the  present  time  it  is,  however,  scarcely  proper  for  any  one  without 
special  training  to  undertake  this  operation.  It  is  better  to  have  the  patient 
examined  with  the  bronchoscope  and  the  attempt  at  removal  made  by  an 
expert. 

So  long  as  the  object  is  in  the  trachea  its  removal,  if  this  does  not  occur 
spontaneously  upon  opening  the  trachea,  can  be  accomplished  by  any  sur- 
geon with  ordinary  skill  and  experience,  while  if  it  has  passed  beyond  the 
bifurcation  of  the  trachea  then  one  side  of  the  lungs  is  free  and  there  is  no 
danger  of  the  patient  losing  his  life  from  asphyxiation ;  at  the  same  time  the 
removal  of  the  foreign  body  becomes  thus  very  much  more  difficult,  and 
hence  there  are  two  very  good  reasons  why  the  patient  should  be  taken  to  an 
expert. 

At  times  parents  are  not  certain  as  to  whether  a  foreign  body  has  actu- 
ally been  inspired.  In  these  instances  the  patient  frequently  does  not  reach 
the  care  of  a  surgeon  until  the  body  has  ulcerated  through  the  wall  of  the 
bronchus  and  into  the  lung,  giving  rise  to  the  formation  of  an  abscess  of 
the  lung.  In  these  cases  skiagrams  should  be  made  both  from  an  antero- 
posterior,  and  from  a  lateral  view,  in  order  to  locate  the  object  as  nearly  as 
possible. 

The  treatment  indicated  is  that  advised  for  abscess  of  the  lung  from  any 
cause.  These  operations  should  be  performed  in  the  pneumatic  cabinet,  or 
with  the  help  of  the  Fell  bellows,  because  in  this  way  the  danger  from 
pneumothorax  can  be  avoided,  the  operation  performed  with  much  less  hurry 
and  the  risk  reduced  to  a  minimum. 


PART  V. 


GENERAL  SURGERY  OF  THE  ABDOMEN. 

There  are  a  few  conditions  connected  with  abdominal  surgery  which 
may  be  considered  in  a  general  way  as  they  apply  to  all  operations  in  which 
the  abdominal  cavity  is  opened. 

Preparatory  Treatment. 

In  performing  intra-abdominal  operations  the  matter  of  space  is  of 
great  importance,  because  an  abundance  of  room  facilitates  the  operation  to 
a  marked  degree. 

It  is  astonishing  how  much  space  may  be  gained  by  securing  an  empty 
condition  of  the  stomach  and  intestines.  If  these  are  filled  with  food,  gas 
and  residue,  the  simplest  operation  may  be  quite  difficult,  while  it  will  be 
many  times  less  troublesome  if  the  intestines  are  as  empty  as  possible. 
Moreover,  the  proximity  to  the  seat  of  operation  of  decomposing  intestinal 
contents  is  not  to  be  desired.  With  only  the  thickness  of  the  intestinal  wall 
between  the  wound  and  this  material  the  patient  is  not  nearly  so  safe  as  he 
would  be  were  the  alimentary  canal  empty. 
Cathartics. 

No  other  cathartic  has  accomplished  this  condition  so  thoroughly,  in  our 
experience,  as  castor  oil,  given  in  the  foam  of  beer  or  malt  extract  on  the  day 
preceding  the  operation.  We  have  found  that  two  ounces  is  the  most  satis- 
factory dose.  If  given  in  this  manner  it  rarely  nauseates  the  patient,  it 
causes  very  little  or  no  pain,  and  it  is  certainly  effective  in  almost  every  case, 
leaving  the  intestines  free  from  gas  and  feces.  It  is  well  to  give  only  steril- 
ized food  for  twenty-four  hours  previous  to  the  operation,  preferably 

sterilized  milk  or  broths. 

» 
Diuretics. 

After  many  intra-abdominal  operations  there  seems  to  be  an  interfer- 
ence with  the  functional  activity  of  the  kidneys,  rather  more  marked  than  in 
any  other  operations  not  performed  directly  upon  the  kidneys  or  urinary 
tracts.  It  is  consequently  wise  to  encourage  their  activity  on  the  day  before 
the  operation  by  giving  pure  water,  preferably  hot,  in  considerable  quanti- 
ties. 

The  hot  bath  which  has  been  mentioned  in  connection  with  the  prepara- 
tion of  patients  for  operation  in  general  is  especially  useful  in  these  patients, 
because  it  stimulates  the  process  of  elimination  through  the  skin  as  well  as 
through  the  kidneys.  In  case  there  should  be  a  lack  of  excretion  of  urine 
this  can  usually  be  induced  by  administering  an  enema  of  one-half  pint  of 
normal  salt  solution  every  hour  until  the  condition  is  relieved.  To  these 
enemata  from  10  to  25  grains  of  acetate  of  soda  may  be  added  until  there  is 


224  GENERAL     SURGERY     OF     THE      ABDOMEN 

a  free  flow  of  urine.  The  same  result  may  be  accomplished  in  an  admirable 
manner  by  the  continuous  proctoclysis  introduced  by  Murphy  and  described 
elsewhere  herein,  normal  salt  solution  being  employed  in  this  as  in  other 
cases.  In  cases  in  which  this  does  not  bring  satisfactory  results  1,000  cc. 
of  normal  salt  solution  may  be  injected  subcutaneously  before  and  after  the 
operation. 

Abdominal  Incisions. 

In  making  an  incision  through  the  abdominal  wall,  the  anatomical  lay- 
ers composing  this  wall  should  be  considered,  for  if  they  are  not  the  closure 
of  the  cavity  after  the  intra-abdominal  operation  has  been  completed  may  not 
be  satisfactory  and  may  result  in  a  weakened  point  in  the  wall  which  may 
presently  develop  into  a  hernia,  and  this  may  be  a  many  times  more  serious 
affliction  to  the  patient  than  the  condition  for  which  the  operation  was  orig- 
inally undertaken. 

Plate  XIII  shows  the  arrangement  of  the  layers  of  the  abdominal  mus- 
cles, together  with  the  location  and  direction  of  the  usual  incisions  through 
the  abdominal  wall  in  the  median  line  and  on  the  right.  Of  course,  the 
same  relative  positions  would  be  suitable  on  the  left  side,  although  on  ac- 
count of  the  location  of  the  gall  bladder  and  the  vermiform  appendix  on 
the  right  side,  many  more  abdominal  sections  are  made  through  this  than 
through  the  left  abdominal  wall. 

The  incision  marked  a  is  suitable  for  all  operations  upon  intra-abdom- 
inal organs  located  in  the  pelvis.  In  cases  of  chronic  appendicitis  the  vermi- 
form appendix  can  also  be  removed  through  this  incision. 

The  incision  marked  b  is  suitable  in  cases  in  which  the  vermiform  ap- 
pendix and  the  right  ovary  and  tube  are  implicated ;  d  indicates  the  incision 
known  as  McBurney's,  for  the  removal  of  the  appendix;  c  is  favorable  for 
operations  upon  the  gall  bladder,  and  the  appendix  can  usually  also  be  re- 
moved through  this  incision ;  e  offers  the  same  advantages  in  the  hypo- 
chondriac region  that  d  gives  in  the  iliac  region ;  /  furnishes  an  approach  to 
the  stomach  ;  although  we  more  frequently  use  incision  c  for  this  purpose,  be- 
cause, through  this  incision  we  can  more  conveniently  inspect  the  gall  blad- 
der, duodenum  and  appendix. 

In  a  and  /  the  incision  is  made  through  the  linea  alba  between  the  recti 
muscles ;  b  and  c  split  the  fibers  of  the  recti  muscle,  and  e  and  d  split  the 
fibers  of  the  external  oblique,  then  the  edges  of  this  muscle  are  retracted  and 
then  the  fibers  of  the  internal  oblique  are  separated,  the  incision  extending  at 
right  angles  to  the  fibers  of  the  external  oblique.  The  incision  is  then  ex- 
tended through  the  fibers  of  the  transversalis  fascia  and  the  peritoneum. 

In  all  of  these  incisions  none  of  the  abdominal  muscles  is  cut  at  right 
angles,  which  is  of  the  greatest  importance,  for  were  they  cut  at  right  angles 
their  ends  would  be  retracted,  and  the  more  the  muscles  contract  obviously 
the  more  the  wound  shows  a  tendency  to  gape.  In  closing  a  wound  in  the 
abdominal  walls  in  which  some  of  the  muscles  have  been  cut  at  right  angles, 
it  is  often  impossible  to  secure  a  satisfactory  union  between  the  cut  ends  of 
the  muscle. 

The  conditions  are  entirely  different  if  the  muscle  fibers  have  only  been 
split  according  to  the  scheme  indicated  in  Plate  XIII  as  the  natural  contrac- 
tion of  these  muscles  has  a  tendency  to-  bring  their  edges  close  together  and 
to  cause  a  spontaneous  closure  of  the  abdominal  wound  in  this  manner. 

Each  one  of  these  incisions  will  be  carefully  described  and  illustrated 
in  connection  with  cases  in  which  it  is  to  be  employed. 


PLATE  XIII. 

LOCATION   OF  ABDOMINAL   INCISIONS. 

Represents  the  abdominal  muscles  with  the  various  lines  of  incisions  indicated 
on  the  right  side;  the  same  incisions  may,  of  course,  be  practised  on  both  sides  of 
the  abdomen,  but  the  location  of  the  vermiform  appendix  and  the  gall  bladder  makes 
these  incisions  more  common  on  the  right  side.  On  the  left  side  the  external  oblique 
abdominal  muscle  has  been  removed,  showing  the  rectus  abdominis  and  the  internal 
oblique:  (a)  represents  the  incision  through  the  linea  alba  below;  (f)  above  the 
umbilicus;  (b)  through  the  outer  edge  of  the  right  rectus  abdominis  muscle  below; 
(c)  above;  (d)  McBurney's  incision;  (e)  the  same  incision  over  the  kidney. 


GENERAL     SURGERY     OF      THE     ABDOMEN 

These  incisions  may,  of  course,  be  changed  as  regards  their  distance 
from  the  median  line,  their  length  and  their  position  upon  the  abdomen,  so 
long  as  their  direction  corresponds  with  that  of  the  muscles  of  the  abdominal 
wall. 

In  order  to  make  the  position  of  these  incisions  more  clear,  they  are 
shown  in  Plate  XIV  upon  the  surface  of  the  body,  without  indicating  the 
direction  of  the  underlying  muscles,  using  the  same  letters  as  in  Plate  XIII 
for  the  various  incisions. 

Traumatism. 

In  no  field  of  surgery  is  it  more  important  to  avoid  unnecessary  trauma- 
tism  than  in  the  abdomen.  This  can  be  accomplished  by  eliminating  from 
the  field  of  operation  the  portions  not  implicated  in  the  disease  by  tamponing 
them  away  with  large  pads  of  soft,  aseptic  gauze,  moistened  with  warm,  nor- 
mal salt  solution.  These  pads  should  be  applied  carefully  and  gently,  in  or- 
der not  to  cause  any  traumatism,  and  left  in  place  until  the  operation  upon 
the  diseased  portion  has  been  completed. 

None  of  the  intra-abdominal  tissues  not  implicated  in  the  disease  should 
be  manipulated  during  the  operation,  in  order  to  avoid  unnecessary  shock 
and  possible  infection  and  consequent  adhesions.  Manipulation  in  inflamed 
or  congested  intra-abdominal  organs  is  especially  likely  to  give  rise  to  shock, 
and  in  these  cases  it  is  consequently  even  more  important  to  limit  the  manip- 
ulations as  much  as  possible.  So  long  as  the  peritoneal  surface  has  not  be- 
come abraded  the  likelihood  of  infection  is  very  greatly  reduced,  and  the 
less  these  organs  and  tissues  are  manipulated  the  less  likely  are  they  to 
suffer  the  abrasion  of  their  peritoneal  surfaces. 

Gaseous  Distension. 

Much  of  the  discomfort  following  abdominal  sections  results  from 
gaseous  distension  of  the  intestines.  This  can  be  reduced  to  a  very  marked 
extent  if  the  alimentary  canal  has  been  thoroughly  emptied  before  the  op- 
eration and  if  no  food  be  given  by  mouth  for  a  day  or  two  after  the  opera- 
tion. 

The  patient  may  be  supported  very  well  by  the  administration  of  one  of 
the  numerous  predigested  foods  in  the  market  given  bv  enema.  One  ounce 
of  this  is  given  in  three  ounces  of  normal  salt  solution  every  three  to  four 
hours.  Or  if  this  is  not  convenient,  a  simple  enema  of  eight  to  sixteen 
ounces  of  normal  salt  solution  given  every  three  to  four  hours  seems  to  re- 
lieve the  sense  of  hunger. 

Both  hunger  and  thirst  after  operation  are  relieved  by  the  use  of  con- 
tinuous normal  salt  solution  proctoclysis.  It  is  usually  best  to  give  this  for 
two  hours  continuously,  then  to  interrupt  it  for  two  hours  or  until  the  patient 
becomes  thirsty,  and  then  to  repeat.  This  also  is  an  excellent  means  for 
preventing  shock. 

The  amount  of  pain  suffered  after  an  intra-abdominal  operation  is  also 
greatly  reduced  if  no  food  be  given  by  mouth.  In  case,  however,  there 
should  still  be  a  considerable  amount  of  pain,  this  may  be  relieved  safely  by 
the  use  of  morphia  hypodermically.  This  is  not  safe  when  food  has  been 
administered,  because  the  relaxing  influence  of  morphia  upon  the  intestinal 
walls  will  have  a  tendencv  to  increase  the  gaseous  distension  and  the  conse- 
quent absorption  of  products  of  decomposition.  \Ve  wish  to  emphasize  this 
point  most  vigorously,  because  nothing  can  be  more  harmful  after  abdominal 
operations  than  the  use  of  opium  or  morphia  in  any  manner  if  some  form  of 


228  GENERAL     SURGERY     OF     THE     ABDOMEN 

nourishment  is  given  by  mouth  at  the  same  time ;  while  in  cases  in  which  the 
canal  has  been  thoroughly  emptied  before  the  operation  by  the  use  of  four 
tablespoonfuls  of  castor  oil  these  remedies  may  be  employed  in  reasonable 
amounts  with  great  benefit  to  the  patient  and  entirely  without  danger. 

It  is  this  tendency  to  decomposition,  in  place  of  digestion  of  food  given 
by  mouth  shortly  after  an  operation,  which  makes  it  virtually  of  no  use  to  the 
patient,  because  he  obtains  no  nourishment  from  the  food  so  taken,  while  the 
absorption  of  the  products  of  decomposition  is  a  real  injury.  There  is,  of 
course,  the  further  advantage  in  this  feature  of  the  after-treatment  that  it 
secures  a  condition  of  rest  for  the  tissues  which  have  been  subjected  to 
traumatism,  which  in  itself  is  of  very  great  importance. 

APPENDICITIS. 

In  the  consideration  of  this  subject  we  will  take  a  number  of  cases 
which  have  come  under  care  and  follow  them  through  the  various  stages  of 
their  disease,  precisely  as  they  progressed,  which  will  doubtless  give  a  much 
more  satisfactory  idea  of  the  plan  of  treatment  we  would  advise  than  in 
describing  the  treatment  without  reference  to  actual  clinical  cases. 

CHRONIC  RECURRENT  APPENDICITIS. 

Typical  Instance. 

A  patient  forty-four  years  of  age,  a  machinist  by  occupation,  gives  the 
following  history :  Ever  since  he  was  a  boy  he  has  had  occasional  attacks  of 
severe  colicky  pains  in  the  abdomen.  These  were  always  accompanied  by 
nausea,  never  by  chills  or  vomiting.  From  the  age  of  twenty  to  thirty-two 
he  always  carried  some  morphine  pills,  which  he  took  during  these  attacks, 
which  never  lasted  more  than  a  few  hours.  At  this  time  a  diagnosis  of  gall 
stones  was  made.  He  always  abstained  from  taking  food  during  the  attack 
and  ate  sparingly  for  a  week  or  two  following.  At  times  the  attacks  oc- 
curred every  week,  then  they  would  disappear  for  a  month,  then  for  six  or 
eight  months,  and  between  the  age  of  thirty-four  and  forty-two  he  was  en- 
tirely free  from  actual  attacks,  but  constantly  suffered  from  digestive  dis- 
turbances. Fifteen  months  ago  he  had  a  recurrence  which  was  more  severe 
than  any  he  could  recall.  It  compelled  him  to  remain  in  bed  for  several 
days  and  left  a  point  in  the  right  inguinal  region  which  was  tender  upon 
pressure.  Since  that  time  he  has  had  eight  attacks,  each  one  a  little  more 
severe  than  the  previous,  and  each  sufficiently  severe  to  prevent  him  from 
going  to  his  work  for  from  three  to  ten  days.  His  last  attack  commenced 
ten  days  ago  and  he  has  been  confined  to  bed  during  this  time,  although  he 
has  not  been  severely  ill.  During  these  attacks  he  has  abstained  from  food 
for  the  first  two  to  five  days,  and  after  that  he  would  take  soups  and  milk. 

He  is  a  slightly  built  man,  muscular  development  good.  Heart,  lungs, 
liver  and  kidneys  normal ;  abdomen  soft.  Upon  inquiry  he  points  to  the 
right  inguinal  region  as  the  seat  of  his  trouble.  Nothing  abnormal  can  be 
found  here  except  pain  upon  deep  palpation.  This  also  reveals  an  area  of 
induration,  which  is,  however,  very  small.  His  temperature  is  below  100° 
F.,  pulse  88,  tongue  coated. 

One  peculiarity  to  which  the  patient  directs  attention  is  the  fact  that 
during  the  early  attacks  the  pains  were  spasmodic  and  came  in  waves.  The 
patient  describes  them  as  though  something  were  grasping  a  tender  portion 


PLATE  XIV. 

LOCATION  OF  ABDOMINAL   INCISIONS. 

Represents  the  same  incisions  as  shown    in    Plate    XIII    drawn    upon    the    skin. 
The  various  incisions  are  lettered  to  correspond  in  the  two  plates. 


GENERAL     SURGERY     OF     THE     ABDOMEN  23! 

of  his  intestine  and  squeezing  it  and  then  loosening  the  grasp,  only  to  tighten 
again.  During  the  past  two  years  this  condition  has  changed  and  now  the 
pain  is  more  constant  and  dull. 

We  would  explain  the  peculiarity  regarding  the  character  of  the  pain 
by  the  change  in  the  tissues  of  the  appendix.  The  muscular  coats  have  suf- 
fered severely  and  do  not  respond  to  irritation  as  they  did  at  first,  conse- 
quently the  spasmodic  character  of  the  pain  has  disappeared. 

This  is  not  at  all  an  uncommon  history.  t\n  individual  formerly  in 
apparently  perfect  health  and  able  to  perform  hard  labor,  suffers  for  a 
period  from  a  moderate  disturbance  of  the  digestion ;  then  there  is  an  acute 
attack  of  appendicitis  from  which  the  patient  recovers  only  to  find  the  diges- 
tive disturbance  exaggerated.  He  returns  to  work,  but  soon  has  a  second 
acute  attack  of  appendicitis,  from  which  he  again  recovers,  only  to  repeat 
his  former  experience.  If  he  has  his  own  business,  or  is  engaged  in  the 
pursuit  of  a  profession,  he  soon  falls  behind  his  competitors  and  is  compelled 
to  make  great  sacrifices.  If  he  is  in  the  service  of  others  his  employer  will 
soon  replace  him  by  a  man  who  can  be  depended  upon. 

Prognosis. 

Many  of  these  patients  have  been  encountered  suffering  from  chronic 
recurrent  appendicitis  whose  prospects  in  life  have  been  ruined  on  account 
of  their  disease.  This,  in  itself,  is  an  ample  indication  for  radical  treatment, 
provided  that  it  will  not  result  in  complications  and  is  not  connected  with 
much  danger,  but  is  likely  to  result  in  a  permanent  cure. 

There  are  yet  other  valid  reasons  why  an  attempt  should  be  made  to 
relieve  the  patient  permanently.  With  each  successive  acute  attack  he  is  ex- 
posed to  a  certain  amount  of  danger  to  life.  The  fact  that  a  patient  has  re- 
covered from  several  attacks  does  not  indicate  that  he  will  always  in  the 
future  be  so  fortunate.  Each  attack  undoubtedly  exposes  the  patient  to  much 
more  danger  than  u'onld  an  operation  for  the  removal  of  the  appendix. 

Moreover,  the  fact  that  his  digestion  is  becoming  more  and  more 
impaired  is  certain  to  affect  his  chances  for  a  long  life.  It  is  likely  that  this 
indigestion  results  in  the  absorption  of  a  considerable  amount  of  products 
of  decomposition.  In  the  same  way,  septic  material  is  likely  to  be  absorbed 
from  the  lumen  of  the  obstructed  appendix. 

That  a  permanent  cure  is  to  be  looked  for,  after  the  removal  of  the 
diseased  appendix,  we  know  from  clinical  experience.  The  conditions  for 
operation  are  so  favorable  that  complications  or  unfavorable  secondary 
effects  are  not  to  be  expected.  The  general  condition  of  the  patient  is  fair, 
his  temperature  and  pulse  are  normal,  he  is  not  suffering  from  an  acute 
infection.  It  has  been  possible  to  empty  the  intestines  thoroughly  before  the 
operation,  which  will  facilitate  the  operation  and  the  recovery.  It  will  not 
be  necessary  to  cause  much  traumatism,  and  any  abrasions  which  may  occur 
in  loosening  adhesions  can  readily  be  covered  with  peritoneum.  It  will  not 
be  necessary  to  drain  the  abdominal  wound  or  to  make  this  especially  large, 
hence  there  need  be  no  fear  of  the  occurrence  of  a  ventral  hernia.  Conse- 
quently we  can  reasonably  eliminate  the  fear  of  complications. 

Concerning  the  danger  of  the  operation  we  would  say  that  in  our  own 
experience  there  has  been  a  mortalitv  in  cases  like  the  one  outlined  of  less 
than  one  in  five  hundred,  or  one-fifth  of  one  per  cent.,  and  such  mortality 
rests  upon  accidents  which  might  occur  with  the  simplest  operation  of  any 
kind. 


232  GENERAL     SURGERY     OF     THE     ABDOMEN 

For  these  reasons  we  advise  the  removal  of  the  appendix  in  cases  of 
which  the  above  is  a  type. 

Technique. 

We  wish  to  direct  attention  to  the  fact  that  such  a  patient's  abdominal 
walls  are  loose  and  that  the  intestines  are  not  at  all  distended  with  gas.  This 
is  due  to  the  preparatory  treatment  consisting  in  the  administration  of  two 
ounces  of  castor  oil  twenty-four  hours  before  and  a  sterilized  liquid  diet 
for  the  same  period. 

The  field  of  operation  being  prepared  in  the  usual  way  is  separated 
from  the  remaining  portion  of  the  surface  of  the  body  by  means  of  sterilized 
towels,  a  sufficient  amount  of  space  being  left  free  so  that  all  the  manipula- 
tions necessary  during  the  operation  may  be  carried  out  without  disturbing 
the  towels,  for  we  must  not  carry  any  infectious  material  from  the  lower 
surface  of  these  towels  to  the  seat  of  operation. 

Abdominal  Wound. 

The  incision  is  made  parallel  with  Poupart's  ligament,  shown  in  Plates 
XIII  and  XIV  d,  crossing  a  point  half  way  between  the  anterior  superior 
spine  of  the  ilium  and  the  umbilicus,  so  that  one-third  of  the  incision  will  be 
toward,  and  two-thirds  away  from,  the  median  line  of  the  body  as  regards 
the  above  point.  This  incision  is  carried  down  through  skin,  fascia,  fat  and 
the  external  oblique  abdominal  muscle  and  fascia,  splitting  the  fibers  of  the 
latter  in  their  course.  The  cut  through  the  external  oblique  may  be  made  an 
inch  shorter  than  that  in  the  skin  and  it  will  still  furnish  a  sufficient  amount 
of  space.  The  edges  are  now  retracted  and  the  direction  of  the  fibers  of 
the  internal  oblique  abdominal  muscle  may  be  seen  at  right  angles  to  the 
incision.  These  fibers  are  also  separated  without  cutting,  and  we  expose  the 
strong  transversalis  fascia,  which  is  closely  attached  to  the  peritoneum. 
This  is  picked  up  between  two  pairs  of  dissecting  forceps,  one  in  the 
surgeon's  hand  and  one  in  the  hand  of  an  assistant.  It  requires  a  little  care 
to  avoid  picking-  up  omentum  or  intestines  at  the  same  time,  but  by  lifting 
the  transversalis  fascia  with  one  pair  of  forceps,  then  picking  it  up  with  the 
other,  then  changing  the  position  of  the  first  pair  slightly,  any  intestine  or 
omentum  which  may  have  been  included  at  first  is  likely  to  be  dropped.  The 
transversalis  fascia  and  the  peritoneum  are  incised  carefully,  then  a  pair  of 
small  hemostatic  forceps  is  applied  to  the  edge  of  this  wound  or  it  is  trans- 
fixed with  needle  and  silk  to  facilitate  its  manipulation  when  the  wound  is 
to  be  closed. 

Guides  to  the  Appendix. 

The  omentum  immediately  comes  into  view  crowding  itself  into  the 
opening  to  protect  the  underlying  intestines.  When  this  is  pushed  to  one 
side  the  cecum  is  exposed.  This  can  be  recognized  by  the  band  of  longitud- 
inal muscles  extending  along  the  anterior  surface  of  this  portion  of  the 
intestine.  Following  this  band  downwards  invariably  leads  to  the  appendix. 
By  bearing  this  fact  in  mind  it  is  possible  to  find  the  appendix  with  the 
slightest  amount  of  disturbance  of  the  abdominal  organs ;  the  manipulations 
being  confined  to  a  very  small  area.  Where  repeated  recurrences,  with  their 
acute  inflammatory  disturbances,  have  resulted  in  extensive  adhesions,  the 
appendix  may  be  club-shaped  at  the  end  and  somewhat  bent  upon  itself.  Its 
proximal  third  may  be  loosely  adherent  to  the  lower  end  of  the  cecum, 
while  the  remaining  portion  is  strongly  adherent  to  the  anterior  surface  of 
the  iliacus  muscle. 


PLATE  XV. 

EXCISION  OF  APPENDIX. 

Represents  the  excision  of  the  vermiform  appendix,  a  clamp  being  placed  at  the 
base  of  the  appendix,  a  second  one  upon  the  mesenteriolum  ;  a  ligature  is  in  position 
to  tie  the  mesenteriolum;  the  scissors  are  in  position  to  cut  the  mesentery  between 
the  appendix  and  the  clamp  upon  the  former;  a  purse-string  suture  has  been  placed 
about  the  base  of  the  appendix  nnon  the  end  of  the  caecum. 


GENERAL     SURGERY     OF      THE     ABDOMEX  235 

Adhesions. 

In  separating-  adhesions  it  is  always  necessary  to  exercise  the  greatest 
care,  because  occasionally  a  small  abscess  may  remain  for  a  considerable 
period  of  time  after  an  acute  attack  of  appendicitis,  and  if  the  appendix 
is  peeled  out  carelessly  it  is  very  possible  for  the  pus  to  come  in  contact 
with  other  parts  of  the  peritoneal  cavity  and  a  peritonitis  may  then  occur. 
Again,  a  perforation  into  the  cecum,  or  the  ileum,  may  have  occurred  during 
the  acute  attack  and  the  communication  between  the  lumen  of  the  appendix 
and  the  intestine  may  not  have  healed  entirely,  and  upon  removing  the 
appendix  a  small  intestinal  fistula  may  be  left,  which  again  may  become  the 
cause  of  a  peritonitis.  In  case  there  is  an  attachment  to  the  cecum  or  ileum 
the  surface  from  which  the  appendix  has  been  removed  should  be  covered 
at  once  by  means  of  a  few  Lembert  sutures. 

Again  it  may  happen  that  the  lumen  of  the  appendix  at  its  cecal  end  is 
occluded  and  that  the  sac  which  is  thus  formed  is  filled  with  pus.  Unless 
great  care  is  exercised  in  dissecting  the  appendix  out  of  its  adhesions  it  is 
liable  to  perforate  during  the  operation  and  cause  an  infection. 

Removing  the  Appendix. 

The  removal  of  the  appendix  may  now  be  accomplished  as  illustrated  in 
Plate  XV.  First  a  pair  of  forceps  is  applied  to  the  mesentery  of  the  ap- 
pendix. (2)  The  mesentery  is  severed  between  the  appendix  and  the 
forceps.  (3)  A  second  pair  of  forceps  is  applied  to  the  appendix  at  the 
point  of  its  origin  from  the  cecum.  (4)  The  mesentery  of  the  appendix  is 
ligated  and  the  forceps  holding  this  structure  is  removed.  (5)  A  purse- 
string  stitch  is  applied  from  one-eighth  to  one-fourth  of  an  inch  from  the 
base  of  the  appendix.  These  steps  are  shown  in  Plate  XV,  although  in 
practice  the  forceps  on  the  mesentery  is  removed  before  the  purse-string 
suture  is  applied.  The  presence  of  the  forceps  on  the  appendix  facilitates  the 
application  of  the  purse-string  suture  and  at  the  same  time  acts  after  the 
fashion  of  an  angiotribe  crushing  the  tissues  of  the  appendix  into  a  thin 
layer,  as  shown  in  Plate  XVI. 

The  appendix  is  now  cut  awav  even  with  the  forceps,  care  being  taken 
to  prevent  leakage  by  applying  another  pair  of  forceps  half  an  inch  nearer 
the  distal  end  of  the  appendix  before  cutting  it  away.  The  crushed  stump 
of  the  appendix  is  then  grasped  by  a  pair  of  smooth  dissecting  forceps,  as 
in  Plate  XVI  or  with  a  probe  containing  a  fine  short  needle  at  its  end,  and 
inverted  into  the  cecum  while  an  assistant  draws  the  circular  stitch  tightly, 
thus  closing  the  defect,  as  in  Plate  XVII.  The  defects  caused  by  the 
removal  of  the  appendix  are  then  covered  with  peritoneum  by  means  of  a 
few  sutures  and  then  a  few  more  sutures  are  applied  to  cover  the  space 
occupied  by  the  purse-string  suture,  as  in  Plate  XVIII.  It  is  not  always 
that  these  last  stitches  are  essential,  but  a  little  too  much  care  is  excusable, 
so  long  as  it  is  harmless. 

Ligatures. 

In  some  cases  the  stump  is  very  vascular,  which  may  make  it  desirable 
to  apply  a  fine  catgut  ligature  to  its  crushed  end.  but  this  is  not  usually 
necessary.  In  applying  the  purse-string  suture  the  needle  should  take  a 
sufficiently  deep  bite  to  include  all  the  layers  down  to  the  mucosa,  the  con- 
nective tissue  next  to  the  mucosa  being  the  most  important  layer. 

It  does  not  matter  whether  fine  silk  or  fine  catgut  be  employed  for  these 


236  GENERAL     SURGERY     OF     THE     ABDOMEN 

sutures,  but  in  our  own  practice  fine  silk  or  fine  linen  is  used  for  all  sutures 
applied  to  the  intestinal  walls.  As  a  matter  of  convenience  we  use  an 
ordinary  straight  sewing  needle  or  a  fine  curved  needle  with  the  fine  silk 
double,  in  order  to  prevent  twisting  and  unthreading,  because  the  sutures 
may  be  applied  more  rapidly  in  this  way  than  by  sewing  with  a  single 
thread. 

The  entire  field  of  operation  is  carefully  inspected  once  more  and  if  any 
abrasion  is  found  this  is  covered  with  a  few  Lembert  sutures,  then  the 
intestine  is  dropped  into  the  peritoneal  cavity  and  the  abdominal  wound 
closed  in  the  following  manner : 

Closure  of  the  Abdominal  Wound 

The  peritoneum  and  transversalis  fascia  are  first  united  by  means  of  a 
continuous  catgut  suture,  as  in  Plate  XIX.  In  this  part  of  the  abdominal 
wall  the  transversalis  fascia  is  strong  and  is  sometimes  likely  to  retract  so 
that  it  is  quite  liable  to  be  overlooked.  As  this  error  would  weaken  the 
abdominal  wall  quite  a  little  at  this  point,  it  is  well  to  bring  both  the 
peritoneum  and  the  transversalis  fascia  together  carefully  with  this  suture. 

The  edges  of  the  internal  oblique  muscle  fall  in  apposition  sponta- 
neously as  soon  as  the  peritoneum  and  transversalis  fascia  have  been  sutured, 
and  without  any  further  interference  there  would  probably  be  a  perfect 
union  in  the  layer.  To  insure  this  still  more  fully,  however,  we  apply  one 
or  two,  or  even  three,  interrupted  catgut  sutures  through  this  muscle,  as 
in  Plate  XX.  It  is  important  to  tie  these  sutures  very  loosely,  as  pressure 
necrosis  in  this  position  would  result  in  retraction  of  the  muscle  and  this 
would  of  course,  produce  a  marked  weakening  of  the  abdominal  wall  at  this 
point. 

The  edges  of  the  wound  in  the  external  oblique  muscle  and  fascia  have 
been  held  apart  by  means  of  retractors,  in  order  to  expose  the  internal 
oblique  thoroughly.  These  retractors  are  now  removed  and  immediately 
the  edges  of  the  muscle  and  fascia  approach  each  other.  With  this  natural 
tendency  of  the  edges  in  wounds  of  these  two  muscles  to  approximate 
themselves  without  the  use  of  sutures,  there  need  be  no  fear  of  the  forma- 
tion of  a  post-operative  hernia,  because  these  two  strong  layers  extend  at 
right  angles  to  each  other. 

The  edges  of  the  wound  in  the  external  oblique  muscle  are  now  united, 
as  illustrated  in  Plate  XXI,  care  being  again  used  not  to  draw  the  stitches 
too  tightly  for  the  reason  given  above. 

In  the  three  plates  just  referred  to  deep  silkworm  gut  sutures  are 
figured  as  placed  in  position,  but  not  tied.  These  may  be  used  if  desired 
and  tied  after  the  buried  sutures  have  been  applied,  but  they  are  not 
necessary  to  secure  a  perfect  union  (and  unless  there  is  an  unusual  amount 
of  tension  in  any  case  we  do  not  use  them,  depending  entirely  upon  the 
catgut  sutures).  In  Plate  XXII  these  stitches  are  figured  as  having  been  tied 
and  the  skin  is  being  united  by  means  of  a  continuous,  buttonhole  stitch  of 
horsehair.  The  latter  is  again  used  double,  in  order  to  prevent  unthreading 
of  the  needle.  It  doe?  not  matter  what  form  of  stitch,  or  what  material  is 
used,  for  the  coaptation  of  the  skin  so  long  as  the  material  is  aseptic.  A 
dressing  of  aseptic  gauze  is  applied  to  the  surface  and  held  in  place  with 
broad  rubber  adhesive  plaster  strips,  in  order  to  support  the  abdominal  wall. 
This  is  covered  with  a  sheet  of  sterile  absorbent  cotton  which  is  held  in 
place  with  an  abdominal  binder. 


HHBl 
PLATE  XVI. 

CAECUM  WITH  APPENDIX  REMOVED. 

Represents  the  end  of  the  caecum  after  the  appendix  has  been  cut  away,  the 
remaining  portion  showing  the  effects  of  the  pressure  from  the  clamp.  The  figure 
should  show  the  mesenteriolum  ligated  and  cut.  instead  of  showing  a  slit  in  the 
peritoneum,  covering  the  caecal  end  of  the  ileum. 


V 
PLATE  XVII. 

EXCISION   OF  APPENDIX. 

Represents  the  stump  of  the  appendix  inverted  into  the  caecum  and  the  peritoneum 
closed  with  sutures;  the  purse-string  suture  is  about  to  be  drawn  together  and  tied 
to  bury  the  stump  of  the  appendix. 


PLATE  XVIII. 

EXCISION  OF  APPENDIX. 

Represents  the  appendix  buried  by  a  second  row  of  sutures.  The  longitudinal 
muscular  band  is  shown  to  extend  down  to  the  origin  of  the  appendix  in  each  of 
these  drawings  of  the  caecum. 


GENERAL     SURGERY     OF     THE     ABDOMEN  243 

Pathological  Appearances  of  Appendix. 

The  specimen  is  a  little  over  four  inches  in  length,  which  is  considerably 
less  than  it  was  before  its  removal,  because  the  longitudinal  muscle  fibers 
have  been  contracted,  and  this  has  resulted  in  a  marked  shortening  of  the 
organ.  Its  mesentery  is  quite  thick  and  extends  a  little  beyond  the  end  of  the 
appendix.  This  condition  has  probably  served  to  protect  the  organ  against 
more  extensive  destruction,  because  in  this  way  a  fair  blood  supply  has 
been  insured  to  the  entire  organ,  although  locally  it  may  have  suffered 
severely.  About  one-half  inch  from  its  cecal  end  there  is  quite  a  marked 
narrowing  in  its  lumen,  and  by  inspection  and  palpation  one  may  determine 
the  presence  of  a  considerable  amount  of  cicatricial  tissue  at  this  point. 
The  narrowing  is  shown  in  Plate  XXIII.  Beyond  this  constriction  we  feel 
several  hard  masses  in  the  lumen  of  the  appendix  which  are  undoubtedly 
due  to  fecal  concretions.  Upon  laying  open  the  part,  these  concretions  show, 
by  the  irregularities  forms  into  which  they  have  been  molded  by  the 
irregularities  in  the  lumen  of  the  appendix,  that  they  must  have  been 
in  this  position  for  a  considerable  period  of  time.  (Plate  XXIII.)  The  mucous 
lining  of  the  appendix  shows  a  number  of  cicatrices  resulting  from  ulcers 
which  have  healed,  and  at  the  narrowest  point,  near  the  cecum,  the  entire 
wall  seems  to  be  composed  of  cicatricial  tissue,  showing  that  there  must 
have  been  at  some  time  a  complete  destruction  of  a  portion  of  the  wall  of 
the  appendix.  The  lumen  at  this  point  is  so  small  that  a  slight  edema  would 
suffice  to  close  it  entirely,  and  with  this  closure  would  disappear  the  drainage 
of  the  cavity  of  the  appendix.  The  septic  material  present  in  this  lumen 
would,  of  course,  increase  very  rapidly  so  soon  as  drainage  had  completely 
disappeared,  and  this  would  result  in  a  recurrent  attack. 

The  digestive  disturbances  with  which  such  a  patient  is  afflicted  can  be 
explained,  first,  from  the  interference  with  the  fecal  circulation  because  of 
the  extensive  adhesions  drawing  the  intestines  out  of  place ;  second,  from  the 
fact  that  the  ileo-cecal  valve  prevents  the  passage  of  gas  and  feces  when 
there  is  an  irritation  or  inflammation  in  the  appendix,  and  consequently  the 
constant  inflammation  in  this  organ  for  perhaps  a  number  of  years  results 
in  an  almost  constant  obstruction  to  the  passage  of  gas  and  feces  from  the 
ileum  into  the  cecum,  and  this,  of  course,  causes  digestive  disturbances. 

Atypical  Conditions. 

In  many  of  these  instances  of  chronic  recurrent  appendicitis  it  is  much 
more  difficult  to  remove  the  appendix  than  has  just  been  stated,  because  it 
may  be  located  in  some  position  from  which  it  can  be  dissected  only  with 
great  difficulty.  A  not  uncommon  location  is  on  the  posterior  surface  of  the 
cecum.  Here  it  is  frequently  completely  covered  with  adhesions,  as  shown 
in  Plate  XXIV. 

]n  these  cases  the  end  is  universally  club-shaped  and  filled  with  fecal 
material,  pus  or  mucus.  Frequently  there  has  been  a  perforation  between 
the  appendix  and  the  cecum,  and  occasionally  there  is  a  fistula  which  has 
persisted  for  a  long  time.  The  cecum,  together  with  the  appendix,  may  be 
united  by  adhesions  to  the  anterior  surface  of  the  iliacus  muscle  or  to  the 
omentum,  or  to  both.  The  appendix  may  also  be  displaced  very  greatly.  It 
has  been  found  attached  to  the  left  of  the  median  line,  even  to  the  border 
of  the  spleen.  We  have  found  it  attached  to  each  of  the  pelvic  organs, 
uterus,  bladder,  ovaries,  tubes,  sigmoid  flexure  and  rectum ;  also  to  the 
small  intestines,  to  the  anterior  abdominal  wall  and  to  the  gall  bladder. 


244  GENERAL     SURGERY     OF     THE     ABDOMEN 

Indeed,  with  a  long,  free  cecum  there  is  no  reason  why  the  appendix  should 
not  be  found  attached  to  any  point  within  the  abdominal  cavity. 

Many  times  we  have  seen  the  appendix  twisted  upon  itself  like  a  snail 
and  held  in  this  position  by  adhesions,  making  the  evacuation  of  its  cavity 
practically  impossible.  In  many  cases  there  are  several  strong  adhesions  at 
various  points  in  the  course  of  the  appendix,  making  short  bends,  which 
have  a  tendency  to  obstruct  its  lumen.  The  distal  end  of  the  appendix  may 
project  beyond  the  last  one  of  these  adhesions  and  form  a  free,  sac-like 
projection. 

It  frequently  happens  that  the  strong  adhesions  are  located  opposite  a 
point  at  which  there  was  a  perforation  in  the  appendix  during  an  acute 
attack.  This  will,  of  course,  still  further  obstruct  the  lumen  of  the  appendix 
at  this  point. 

Plate  XXVI  represents  an  appendix  which  is  fairly  normal  both  at  its 
cecal  and  its  distal  end,  but  severely  obstructed  at  three  intervening  points  on 
account  of  short  bends  due  to  strong  adhesions. 

Occasionally  an  appendix  is  found  in  which  the  greater  portion  of  the 
structure  has  been  destroyed  by  gangrene  and  has  been  absorbed,  leaving 
only  a  small,  string-like  structure  along  the  edge  of  the  mesentery  of  the 
appendix.  Again,  the  cecal  end  may  have  been  destroyed  in  the  same  way, 
leaving  the  distal  end  without  communication  with  the  cecum.  This  condi- 
tion is  likely  to  be  troublesome  because  it  leaves  a  sac  lined  with  mucous 
membrane  containing  septic  material  without  drainage  into  the  cecum. 

In  still  other  cases  the  appendix  has  become  so  intimately  united  with 
the  posterior  surface  of  the  cecum  that  it  can  be  discovered  only  after  the 
most  careful  search  has  been  made,  because  both  the  appendix  and  the 
underlying  cecum  are  covered  with  a  broad  sheet  of  connective  tissue  which 
has  almost  perfectly  the  appearance  of  peritoneum.  In  these  instances  it 
frequently  happens  that  the  proximal  end  of  the  appendix  is  entirely 
occluded  and  that  the  distal  end  contains  septic  material  which  gives  rise  to 
the  recurrent  attacks  of  appendicitis,  which  subside  only  when  the  abscess 
formed  has  perforated  into  the  cecum. 

The  longitudinal  band  of  muscle  fibres  serves  better  than  any  other 
guide  to  the  discovery  of  the  location  of  the  appendix  in  these  examples. 

The  operator  may  easily  be  deceived  in  searching  for  the  appendix,  in 
the  interval  in  recurrent  appendicitis,  by  the  presence  of  a  small  mass  of 
fat  at  the  lower  end  of  the  cecum.  This  may  lead  him  to  suppose  that  the 
appendix  has  been  entirely  destroyed  on  account  of  gangrene  and  that  all 
that  is  left  is  simply  the  fat  mesentery  of  the  appendix.  Careful  inspection 
will  usually  show  that  this  mass  of  fat  consists  of  a  small  portion  of 
omentum  which  has  surrounded  the  appendix  and  has  become  thoroughly 
adherent  to  the  latter  or  to  its  remnant  after  the  portion  destroyed  by  the 
disease  has  been  absorbed.  So  long  as  the  operator  follows  the  longitudinal 
muscle  band  upon  the  anterior  surface  of  the  cecum,  and  at  the  same  time 
is  as  careful  as  possible  not  to  injure  the  walls  of  the  loops  of  intestine 
winch  may  be  adherent,  his  search  for  the  appendix  may  be  conducted  with 
relative  safety. 

Important  Conclusions. 

The  important  points  to  be  borne  in  mind  in  connection  with  recurrent 
appendicitis  are:  I,  The  patient's  opportunities  for  professional  or  business 
prosperity  are  greatly  limited  by  the  frequent  interruptions  due  to  the 


GENERAL     SURGERY     OF     THE     ABDOMEN  245 

disease.  2,  He  is  deprived  of  many  of  the  ordinary  pleasures  of  life.  3,  He 
is  constantly  in  danger  of  suffering  from  a  serious  attack.  4,  His  digestion 
is  impaired  and  his  nutrition  is  correspondingly  reduced.  5,  He  is  forced 
to  absorb  septic  material  during  a  considerable  portion  of  the  time.  6, 
During  any  attack  any  of  the  various  complications  resulting  from  acute 
appendicitis  may  occur.  7,  So  large  a  proportion  of  these  cases  suffer  from 
gall  stones  'that  this  condition  may  be  reasonably  looked  upon  as  being 
secondary  to  the  appendicitis. 

All  of  these  conditions  can  be  eliminated  by  an  operation  which  in  itself 
is  not  accompanied  with  as  much  danger  as  there  is  in  any  one  attack  of 
recurrent  appendicitis,  and  which  will  confine  the  patient  for  a  very  short 
time,  provided,  always,  that  the  operation  is  performed  by  a  safe  surgeon 
and  after  the  acute  attack  has  subsided  completely. 

ACUTE   PERFORATIVE   APPENDICITIS. 

Typical  History. 

The  patient  is  fourteen  years  of  age,  a  school  girl,  slightly  built,  and  not 
well  developed  for  her  age.  She  has  never  been  strong  since  infancy,  which 
she  attributes  to  the  fact  that  she  suffered  from  measles  and  scarlet  fever 
while  very  young.  Her  nutrition  has  always  been  imperfect  and  her 
appetite  unnatural,  being  either  ravenous  or  entirely  absent.  Her  bowels 
have  been  constipated  and  abdomen  bloated.  She  has  menstruated  since  one' 
year  ago  at  irregular  times  and  has  suffered  severely  from  pain  in  the  region 
of  the  right  ovary  during  each  period.  The  pain  has  been  spasmodic  and 
so  severe  that  the  use  of  anodynes  seemed  necessary  for  her  relief.  She 
never  suffered  from  severe  pain  at  any  other  time,  although  she  occasionally 
had  slight  attacks  of  colic  in  the  epigastric  region  whenever  she  was 
especially  careless  about  eating.  Three  clays  ago,  immediately  after  an 
unusually  large  dinner  the  patient  suddenly  experienced  severe  pain  over  the 
entire  abdomen,  but  which  was  more  intense  in  the  vicinity  of  the  umbilicus. 

The  patient  was  put  to  bed  and  hot  cloths  were  applied  to  the  abdomen, 
affording  only  very  slight  relief ;  she  was  then  given  a  large  dose  of  salts, 
followed  by  a  cup  of  hot  water.  Being  slightly  nauseated  before,  this 
condition  increased  very  rapidly,  resulting  in  severe  vomiting,  which  has 
persisted  at  intervals  ever  since.  Two  days  ago  she  received  several  enemata, 
one  of  which  was  followed  by  the  expulsion  of  gas  and  some  feces.  The 
patient  received  soups  and  milk  by  mouth,  but  could  not  retain  the  nourish- 
ment more  than  a  few  hours  at  a  time,  when  she  would  vomit  whatever  had 
been  taken.  All  remedies  administered  to  relieve  the  nausea  and  vomiting 
were  of  no  avail.  Several  further  enemata  were  given  without  effecting  the 
expulsion  of  gas  or  feces.  The  abdomen  became  more  and  more  tympanitic 
and  the  pain  became  so  severe  that  morphia  had  to  be  used  hypodermically. 
The  pulse  increased  to  130  beats  per  minute  and  the  temperature  to  102.5^. 
The  pain  has  become  localized  in  the  right  inguinal  region. 

The  general  appearance  of  the  patient  is  extremely  unsatisfactory.  She 
qives  the  impression  of  one  who  is  almost  hopelessly  ill.  She  has  an  anxious, 
restless  expression.  Her  breathing  is  entirely  costal,  rapid  and  short.  Her 
abdomen  is  severely  distended  and  more  prominent  in  the  right  inguinal 
region  than  in  the  left.  The  abdominal  muscles  are  exceedingly  tense, 
especially  on  the  right  side.  The  patient  shrinks  if  she  notices  any  one  ap- 


246  GENERAL     SURGERY     OF     THE     ABDOMEN 

preaching  the  bed,  although  she  seems  too  ill  to  show  interest  in  anything 
else. 

Upon  percussion  we  find  a  little  difference  in  resonance  in  the  two 
inguinal  regions,  but  neither  side  gives  a  dull  or  a  flat  sound.  The  patient 
complains  of  pain  from  percussion  on  the  right  side. 

Upon  examination  through  the  rectum  we  find  this  organ  distended 
with  gas  above  the  internal  sphincter,  which  is  supposed  to  indicate  the 
presence  of  diffuse  peritonitis.  On  the  right  side  the  finger  perceives  a 
fullness,  but  no  fluctuation.  Her  thighs  are  drawn  up  to  relieve  the  tension 
of  the  abdominal  muscles.  The  nurse  has  placed  a  pillow  under  her  knees 
to  make  this  position  more  comfortable.  The  patient's  temperature  is  nearly 
103°  F.  and  the  pulse  130  beats  per  minute  and  very  feeble.  Her  tongue  is 
thickly  coated  and  the  edges  are  red  in  small  spots.  She  is  intensely  thirsty, 
but  does  not  retain  the  liquid  given  to  her. 

The  patient  is  evidently  suffering  from  acute  perforative  appendicitis 
with  beginning  diffuse  peritonitis.  This  may  be  due  to  the  perforation  of  an 
ulcer  which  has  existed  for  a  considerable  period  of  time,  or  to  gangrene 
of  the  appendix,  from  thrombosis  of  some  of  its  vessels  or  to  the  perforation 
of  an  appendix  distended  with  pus  with  its  cecal  end  occluded  by  cicatricial 
tissue.  The  patient  is  extremely  ill,  and  it  is  plain  that  unless  the  method  of 
treatment  employed  (luring  the  past  three  clays  is  radically  changed  she 
cannot  survive  long. 

'  Considerations  of  Treatment. 

So  far  the  patient  has  received  the  treatment  prescribed  by  many  of  the 
leading  text-books  on  internal  medicine.  She  has  been  limited  to  liquid  diet, 
has  received  saline  cathartics  and  enemata,  has  had  hot  applications  to  the 
abdomen,  and  when  the  pain  has  been  unbearable  opium  was  employed  only 
in  sufficient  doses  to  overcome  the  severe  distress. 

There  can  be  no  doubt  from  the  progress  of  the  disease  that  such 
treatment  was  extremely  unfortunate  in  this  case.  We  believe  that  this  form 
of  treatment  should  be  condemned  in  every  case  of  acute  appendicitis, 
because  it  contains  nothing  which  can  be  useful  for  the  relief  of  the  patho- 
logical conditions  present,  while  it  includes  many  features  which  are  ex- 
tremely harmful,  as  we  shall  see  presently. 

The  giving  of  cathartics  of  any  kind  during  acute  gangrenous  or 
perforative  appendicitis  at  an\  time  during  the  attack  lias  undoubtedly 
destroyed  more  lives  than  surgery  lias  saved  in  this  disease. 

The  question  arises,  What  can  we  do  for  this  patient  that  will  be  of 
greatest  benefit  to  her  and  may  possibly  rescue  her  from  the  present  ap- 
parently hopeless  condition  ? 

Many  authors  advise  an  immediate  operation  in  all  cases  of  acute 
appendicitis  without  regard  to  the  condition  of  the  patient  or  the  stage  of 
the  attack,  unless  the  patient  is  moribund  on  the  one  hand  or  improving 
rapidly  under  the  treatment  which  is  being  employed  at  the  time  the  surgeon 
is  called. 

Although  this  example  patient  is  very  ill,  she  is  not  moribund,  conse- 
quently this  case  would  come  under  the  class  in  which  an  immediate  opera- 
tion is  advised  by  these  authorities.  In  our  experience,  and  in  that  of  all 
surgeons  whose  work  we  have  had  an  opportunity  to  observe,  patients  with 
the  conditions  of  the  case  described  have  almost  invariably  died  within 
twenty-four  or  forty-eight  hours  after  the  operation.  They  therefore  belong 


PLATE  XIX. 

Mc.bUK.Niil    b     l-x^uiON. 

Represents  McBurney's  incision  for  the  removal  of  the  vermiform  appendix,  the 
deep  silkworm  gut  sutures  are  in  place,  hut  not  tied,  the  peritoneum  and  transversalis 
fascia  being  united  with  a  separate  row  of  continuous  cat-gut  sutures;  the  internal 
oblique  abdominal  muscle  being  split  with  the  edges  still  separated.  The  edges  of 
the  external  oblique  addominal  muscle  are  held  apart  with  retractors. 

It  is  nrt  r<  ccs-ary  to  insert  the  deep  silkworm  gut  sntnres,  the  catgut  sutures 
uniting  the  various  layers  being  quite  sufficient  to  secure  perfect  nrcl  permanent  union. 


GENERAL     SURGERY     OF      THE     ABDOMEN  249 

to  a  class  in  which  operative  treatment  has  an  especially  high  mortality.  In 
fact,  by  far  the  greater  portion  of  all  fatal  cases  following  appendicitis 
operations  belong  to  this  class.  These  cases  have  been  said  to  be  too  late 
for  an  early,  and  too  early  for  a  late  operation. 

Our  experience  has  been  quite  different  with  a  form  of  treatment  which 
we  will  proceed  to  set  forth.  Of  course,  no  form  of  treatment  can  save 
every  case  of  perforative  appendicitis,  especially  if  the  patient  has  received 
cathartics  and  food  by  mouth  before  he  comes  under  care,  but  in  cases  like 
the  one  depicted  we  would  estimate  the  proportion  of  recoveries  at  about 
ninety  per  cent,  if  the  method  which  we  recommend  be  employed. 

Taking  all  cases  of  gangrenous  and  perforative  appendicitis  together, 
as  a  class,  as  they  come  under  our  care  at  the  hospital  those  that  are  like  the 
case  named  and  those  that  are  not  so  severe  but  still  having  gangrene  or 
perforation  present,  and  those  that  are  still  worse,  our  mortality  is  now  a 
little  less  than  two  per  cent. 

Had  it  been  possible  from  the  beginning  to  confine  the  septic  material 
to  the  vicinity  of  the  appendix,  the  patient's  condition  would  never  have 
become  as  serious  as  at  the  present  time,  because  her  serious  condition  is 
undoubtedly  due  to  the  fact  that  the  septic  material  has  been  distributed 
over  a  considerable  portion  of  the  peritoneum. 

Anatomical  Surroundings  of  the  Appendix. 

In  order  to  comprehend  fully  the  treatment  we  advise  in  this  class  of 
cases,  it  will  be  necessary  to  direct  attention  to  the  anatomical  location  of 
the  appendix. 

The  appendix  is  virtually  surrounded  on  all  sides,  excepting  in  the 
direction  of  the  median  line,  by  relatively  fixed  tissues.  Above  we  find  the 
lower  end  of  the  cecum  and  the  cecal  end  of  the  ileum ;  to  the  right  and  in 
front  is  the  parietal  peritoneum  ;  behind  the  peritoneum  covering  the  iliacus 
muscle ;  and  toward  the  median  line  it  is  surrounded  by  loops  of  small 
intestines.  Moreover,  the  omentum  extends  far  beyond  its  lower  end.  (In 
small  children  the  omentum  is  so  slight  in  many  cases  that  it  cannot  be  con- 
sidered of  great  value  in  protecting  a  gangrenous  appendix.) 

It  is  true  that  the  appendix  may  be  displaced  downward,  but  in  this 
event  it  will  again  be  surrounded  by  fixed  tissues  which  seem  especially 
adapted  to  dispose  of  septic  material.  Again,  there  may  be  an  enteroptosis 
affecting  the  cecum,  and  always  with  this  a  marked  lowering  of  the  trans- 
verse colon  and  stomach,  and  with  these,  the  omentum. 

It  may  also  be  displaced  upwards  and  backwards  in  which  instance  the 
cecum  is  in  a  position  to  furnish  perfect  protection  ;  or  upwards  and  forward 
when  the  omentum  will  be  able  to  surround  it  on  all  sides. 

Thus  we  see  that  the  natural  anatomical  arrangement  for  the  protection 
of  the  general  peritoneal  cavity  is  extremely  efficient.  There  is  but  one  weak 
point  in  the  anatomical  provision  for  this  protection,  namely,  in  the  direction 
of  the  median  line,  because  the  great  mobility  of  the  small  intestines 
naturally  favors  the  distribution  of  septic  material  to  all  parts  of  the 
peritoneal  cavity.  If  we  can  prevent  the  small  intestines  from  doing  harm 
in  this  direction,  we  will  have  accomplished  our  end.  theoretically  at  least. 

At  this  juncture  let  us  direct  attention  to  another  important  anatomical 
condition.  The  blood  supply  of  the  omentum  is  so  enormous  that  it  will 
readily  dispose  of  a  very  severe  infection  by  walling  off  the  surrounding 
structures  if  it  is  permitted  to  give  its  physiological  attention  to  a  single  area. 


25O  GENERAL     SURGERY     OF     THE      ABDOMEN 

It  is  a  well-known  fact,  which  every  one  who  frequently  operates  during 
the  acute  attack  of  appendicitis  has  had  many  opportunities  to  observe,  that 
the  omentum  crowds  itself  about  any  inflammatory  or  traumatic  lesion 
within  the  peritoneal  cavitv  the  moment  such  lesion  occurs,  and  if  left  un- 
disturbed a  few  hours  will  suffice  to  cause  efficient  protective  adhesions. 
These  adhesions  become  stronger  every  hour  and  the  blood  supply  in  the 
omentum  becomes  greater,  so  that  if  no  disturbance  arises  one  can  reason- 
ably c.rpect  efficient  protection  to  the  general  peritoneal  cavity  from  the 
omentum. 

Another  important  fact  must  not  be  lost  sight  of  in  this  connection, 
viz. :  that  the  surrounding  structures  being  relatively  fixed  in  position  favor 
the  condition  of  rest  of  the  inflamed  part  and  permit  the  omentum  to  act 
after  the  manner  of  a  splint  applied  to  an  inflamed  joint.  The  value  of  rest 
as  a  preventative  to  the  extension  of  an  infection  in  any  part  of  the  body 
cannot  be  overestimated.  .Consequently,  if  it  is  possible  for  us  to  secure  this 
condition  of  rest  we  have  gained  another  important  point  in  the  right 
direction. 

Should  the  appendix  be  displaced  upwards  its  position  is  even  more 
favorable,  because  the  available  amount  of  omentum  is  thus  increased. 
Again,  if  the  appendix  is  retro-cecal  in  its  position,  which  is  very  frequently 
the  case,  the  infection  of  the  general  peritoneal  cavity  is  more  easily 
prevented  than  when  in  its  normal  location.  If  anteriorly  misplaced  it  is 
likely  to  be  fastened  to  the  anterior  abdominal  wall  by  the  adherent 
omentum. 

Peristaltic  Motion  of  the  Small  Intestines. 

It  is  plain,  then,  that  the  infection  of  the  general  peritoneal  cavity  must 
occur  from  a  disturbance  on  the  part  of  the  small  intestines  and  must  be 
due  to  their  peristaltic  motion. 

It  is  significant  that  in  almost  all  cases  of  severe,  acute  appendicitis  the 
obstruction  to  the  passage  of  gas  and  intestinal  contents  through  the  ileo- 
cecal  valve  is  one  of  the  earlv  symptoms,  a  condition  which  was  present 
throughout  the  attack  in  the  case  typified.  Nature  is  trying  to  prevent  this 
verv  dangerous  disturbance  by  closure  of  the  ileo-cecal  valve.  \Ye  have  a 
condition  corresponding  to  the  contraction  of  the  muscles  surrounding  an 
inflamed  joint;  to  the  closure  of  the  eye-lids  in  conjunctivitis,  etc.  Moreover, 
the  muscles  overlying  the  appendix  become  tense.  Everything  tends  toward 
the  establishment  of  conditions  of  rest  in  the  vicinitv  of  the  inflamed  organ. 

The  Effect  of  the  Introduction  of  any  Kind  of  Food  or  Cathartic  into  the  Stomach. 

It  is  a  fact  which  has  been  demonstrated  a  great  number  of  times  that 
peristalsis  does  not  occur  unless  food  or  cathartics  are  introduced  into  the 
stomach.  If  the  attack  occurs  shortly  after  a  meal  and  before  all  of  the 
food  has  passed  through  the  ileo-cecal  valve,  its  presence  mav  cause  peri- 
taltic  motion  in  the  small  intestines.  I'pon  reaching  the  ileo-cecal  valve  the 
latter  may  prevent  its  passage  into  the  cecum,  causing  return  peristalsis, 
and  the  intestinal  contents  are  forced  back  into  the  stomach,  from  which 
cavitv  again  to  be  expelled  bv  vomiting,  or  again  forced  into  the  small 
intestines,  giving  rise  to  further  peristaltic  motion.  Moreover,  it  will  give 
rise  to  the  formation  of  gas,  which  must  cause  disturbance  and  pain  in  its 
attempt  to  pass  the  ileo-cecal  valve. 

This  motion,  it  is  plain,  will  be  harmful  primarily  from  the  fact  that  it 
gives  rise  to  pain  bv  disturbing  the  sensitive,  inflamed  tissues;  and,  second- 


GENERAL     SURGERY     OF     THE     ABDOMEN  25! 

arily,  from  its  likelihood  of  carrying  infectious  material,  with  which  the 
intestines  or  the  omentum  have  come  in  contact  in  the  vicinity  of  the 
inflamed  appendix,  to  other  parts  of  the  peritoneal  cavity. 

Besides  this  the  physiological  attention  of  the  omentum  cannot  be 
directed  to  the  single  area  of  infection,  because  other  parts  of  the  peritoneal 
cavity  require  its  protection,  and  such  portions  of  the  omentum  as  are  not 
yet  thoroughly  adherent  about  the  inflamed  appendix  are  inclined  to  be 
diverted  from  this  point. 

Theoretically,  then,  the  disturbance  which  is  to  be  feared  to  so  great  an 
extent  is  caused  by  the  presence  of  food  or  cathartics  in  the  stomach  and 
intestines,  and  its  logical  remedy  would  be  to  absolutely  prevent  the  intro- 
duction of  any  form  of  food  or  cathartics  into  the  stomach  and  the  removal 
by  gastric  lavage  of  any  portion  of  food  that  may  be  retained  in  the  stomach 
at  the  beginning  of  the  attack.  It  may  be  necessary  to  perform  gastric 
lavage  twice,  or  at  most  three  times,  in  order  to  entirely  remove  remnants 
of  food  which  may  have  regurgitated  into  the  stomach  from  the  small 
intestines  by  reason  of  return  peristalsis.  That  this  is  not  only  true  theo- 
retically, but  also  in  practice,  we  have  demonstrated  in  a  large  number  of 
cases ;  and  many  other  surgeons  who  have  followed  the  same  plan  of  treat- 
ment have  informed  us  of  the  fact  that  their  experience  has  agreed  with 
ours. 

It  is  true  that  a  few  surgeons  have  reported  failures  with  this  method, 
but  an  investigation  of  their  treatment  in  each  instance  has  shown  that  they 
disregarded  one  of  the  three  cardinal  points  in  the  treatment.  They  either 
gave  just  a  little  liquid  food  by  mouth,  or  they  gave  some  form  of  cathartic, 
or  disturbed  the  rest  of  the  intestines  by  giving  large  enemata,  or  they 
neglected  removing  the  stomach  contents  by  gastric  lavage. 

Of  course,  the  slightest  amount  of  food  is  sufficient  to  start  peristaltic 
motion  of  the  small  intestines,  and  the  same  is  true  of  cathartics,  and  conse- 
quently if  either  of  these  features  in  the  treatment  be  omitted  one  cannot 
hope  for  the  same  results.  Even  water  given  by  mouth  will  frequently  start 
peristalsis,  and  when  given  rapidly  by  rectum  in  the  form  of  enemata  the 
same  harmful  effect  is  often  experienced,  while  this  is  not  the  case  if  normal 
salt  solution  be  given  by  rectum  continuously  by  the  drop  method  introduced 
by  Murphy. 

Starvation  Plan  of  Great  Value  Unqualifiedly. 

It  seems  clear  that  this  plan  of  treatment  must  be  useful,  in  any  given 
case,  no  matter  what  form  of  appendicitis  mav  be  present,  because  in  the 
milder  cases  it  will  result  in  rest  of  the  affected  part,  and  consequently  rapid 
resolution  ;  in  the  severe  cases  it  will  guard  against  mechanical  distribution 
of  infectious  material ;  and  in  all  cases  it  reduces  the  tendency  to  meteorism 
and  stops  the  pain. 

\Ye  wish,  therefore,  once  more  to  impress  every  one  who  reads  this 
with  the  important  fact  that  no  matter  what  form  of  treatment  he  may  have 
decided  to  carry  out  in  any  given  case  of  acute  appendicitis  his  patient  will 
be  safer  and  more  comfortable,  and  will  make  a  more  rapid  recovery  with 
fewer  complications,  if  he  makes  use.  in  addition  to  the  treatment  con- 
templated, of  the  plan  just  described. 

A  Great  Change  in  Mortality. 

There  is,  particularly,  one  class  of  patients  in  which  we  have  found 
this  treatment  of  the  greatest  value.  \Ye  refer  to  the  class  in  which  the 


252  GENERAL     SURGERY     OF     THE     ABDOMEN 

appendix  is  gangrenous  or  perforated  and  in  which  there  is  already  a 
beginning  of  general  peritonitis.  These  patients  give  the  impression  of  being 
profoundly  ill.  There  is  complete  obstruction  to  the  passage  of  gas  and 
feces.  There  is  nausea  or  vomiting  and  marked  meteorism;  the  pulse  is 
small  and  quick ;  usually  there  is  high  fever,  but  the  temperature  may  be 
subnormal ;  respiration  is  rapid,  superficial  and  costal,  and  the  abdominal 
muscles  overlying  the  appendix  are  tense — conditions  corresponding  to  those 
we  have  just  clinically  outlined.  The  patient  is  in  a  state  in  which  we 
formerly  operated  at  once,  day  or  night,  as  a  last  resort,  only  to  find  that  it 
was  too  late  in  more  than  one-third  of  the  number  of  cases,  the  mortality 
increasing  with  the  time  that  had  elapsed  since  the  beginning  of  the  attack. 

In  this  class  of  cases  there  is  now  a  recovery  of  over  ninety  per  cent., 
and  if  all  cases  of  acute  gangrenous  and  perforative  appendicitis  are 
counted,  of  over  ninety-eight  per  cent.,  if  the  principles  laid  down  above  be 
thoroughly  applied. 

If  peristalsis  is  inhibited,  as  it  can  usually  be,  the  infection  will  become 
circumscribed  and  the  pus  can  be  evacuated  with  safety.  Moreover,  the 
condition  we  have  just  described  is  in  itself  the  result  of  the  administration 
of  food  and  cathartics.  Had  these  patients  received  neither  food  nor  cath- 
artics from  the  beginning  of  their  attack,  the  affair  would  never  have 
advanced  to  this  dangerous  point.  This  refers  particularly  to  a  class  of  cases 
which  Richardson  has  so  well  described  as  being  "too  late  for  an  early,  and 
too  early  for  a  late,  operation." 

If  the  plan  we  have  outlined  above  is  carried  out  the  following  changes 
are  quite  certain  to  occur :  The  nausea  and  vomiting  will  cease  after  one 
or  two,  or  at  most  three,  gastric  irrigations.  The  meteorism  and  the  pain 
will  decrease  greatly  during  the  first  twelve  hours  and  will  almost  com- 
pletely disappear  in  twenty-four  hours.  The  pulse  will  become  slower  and 
firmer  and  more  regular ;  the  breathing  deeper  and  the  patient's  general 
appearance  will  improve  to  an  astonishing  extent.  The  temperature  will  go 
below  100°  F.  the  first  twenty-four  hours,  and  in  three  days  it  will  be 
practically  normal.  The  abdominal  muscles  will  become  soft  as  soon  as  the 
>tomach  contents  have  been  removed  by  gastric  lavage. 

Usually  the  improvement  is  so  rapid  that  one  is  tempted  to  spoil 
everything  by  giving  nourishment  by  mouth,  because  the  patient's  condition 
does  not  seem  serious  enough  to  warrant  such  severe  deprivation  measures. 

That  this  form  of  treatment — which  we  have  employed  since  1892,  at 
first  only  in  selected  cases  and  later  more  and  more  generally — is  really  of 
great  value  is  shown  by  clinical  results.  Our  mortality  in  cases  of  perforative 
or  gangrenous  appendicitis  with  beginning  diffuse  peritonitis  is  less  than 
one-fourth  as  high  as  it  was  in  the  cases  operated  at  once  upon  making  the 
diagnosis,  and  even  in  advanced  cases  of  diffuse  peritonitis  there  has  been  a 
marked  decrease  in  the  mortality  in  our  experience. 

It  might  lie  said  that  these  cases  were  not  due  to  perforative  or 
gangrenous  appendicitis,  but  that  they  were  simply  severe  catarrhal  cases, 
which  are  known  to  result  favorably  under  any  form  of  treatment.  To  this 
we  would  respond  that  we  have  later  removed  the  appendix  in  many  of 
these  cases  and  have  almost  invariably  demonstrated  the  correctness  of  the 
diagnosis. 

Gastric  Lavage  Imperative. 

It  might  seem  impossible,  returning' to  our  clinical  case,  to  remove  more 


PLATE  XX. 

ABDOMINAL   WOUND. 

Represents    the    next    step    in    the    closure    of    McBurney's    incision,    the    internal 
oblique  abdominal  muscle  having  been  united  with  interrupted  cat-gut  sutures. 


GENERAL     SURGERY     OF      THE     ABDOMEN  255 

substance  from  the  stomach  after  she  has  vomited  so  frequently  for  a  period 
of  more  than  two  days.  Frequently  physicians  have  considered  this  step 
superfluous,  because  they  have  imagined  that  the  stomach  must  surely  be 
empty  under  these  conditions.  This  is,  however,  a  very  serious  error.  The 
fact  that  the  patient  is  suffering  from  nausea  or  vomiting  is  the  strongest 
indication  for  the  use  of  gastric  lavage,  because  the  nausea  is  caused  by  the 
presence  of  decomposing  material  in  the  stomach  and  its  removal  must 
result  in  the  greatest  benefit.  It  frequently  happens  that  these  patients  lose 
their  anxious  expression  and  restlessness,  which  we  have  observed  in  this 
case,  and  that  the  skin  becomes  warm  and  moist  and  they  begin  to  sleep 
directly  after  the  gastric  lavage  has  been  practised. 

Were  a  person  in  perfect  health  to  place  in  his  stomach  the  amount  of 
decomposing  food  and  mucus  which  we  have  just  washed  out  of  the  child's 
stomach,  he  would  at  once  become  violently  ill,  and  consequently  the  effect 
of  this  substance  upon  a  patient  whose  strength  has  been  exhausted  by  a 
severe  acute  illness  must  certainly  be  still  worse.  It  is  possible  that  there 
may  be  more  material  of  the  sajne  character  in  the  small  intestines,  but  if 
?o  it  will  soon  regurgitate  into  the  stomach  and  make  its  presence  known 
by  the  recurrence  of  nausea.  Should  this  occur  the  gastric  lavage  should 
be  repeated  at  once.  If  no  food  is  given  by  mouth  we  have  never  been 
compelled  to  irrigate  the  stomach  more  than  three  times  in  the  same  patient, 
and  usually  one  careful,  thorough  irrigation  will  suffice. 

Technique    of   Lavage. 

It  will  be  wise  to  direct  attention  to  the  method  employed  in  such  cases. 
The  patient  is  turned  upon  the  right  side  in  order  to  add  the  weight  of  the 
intestines  to  the  support  of  any  adhesions  which  may  exist  in  the  vicinity  of 
the  appendix.  The  head  and  shoulders  are  slightly  elevated  by  means  of 
pillows  or  a  head-rest,  or  by  elevating  the  head  of  the  bed  from  thirty  to 
fifty  cm.,  then  the  pharynx  is  sprayed  with  a  four  per  cent,  solution  of  cocain 
in  order  to  prevent  gagging  when  the  stomach  tube  is  passed,  because  this 
might  disturb  the  adhesions  in  the  vicinity  of  the  appendix.  It  is  well  to 
spray  the  pharynx  repeatedly  for  a  period  of  about  five  minutes,  permitting 
the  patient  to  swallow  a  little  of  the  saliva  mixed  with  cocain  in  order  to 
anesthetize  the  esophagus  to  some  extent  at  the  ?ame  time,  Not  more  than 
one  teaspoonful  of  the  cocain  solution  should  be  placed  in  the  atomizer  in 
order  to  avoid  harm  from  cocain  poisoning.  After  holding  the  cocain  in  the 
pharynx  a  minute  it  is  expectorated  with  the  saliva  which  has  accumulated 
and  a  fresh  spray  is  applied.  As  most  of  the  cocain  is  thus  thrown  out  there: 
is  no  danger  from  poisoning.  After  about  five  minutes  a  fairly  large  stomach 
tube  is  inserted  and  the  contents  of  the  stomach  siphoned  out.  The  stomach 
tube  should  have  one  or  two  lateral  openings  aside  from  the  opening  at  its 
end.  These  openings  should  be  within  one  to  two  inches  from  the  end  which 
is  inserted  in  the  stomach.  This  will  prevent  the  end  of  the  tube  from 
becoming  closed  by  drawing  into  it  a  portion  of  the  mucous  lining  of  the 
stomach. 

Whenever  there  is  any  interruption  in  the  flow  this  may  be  overcome  by 
pouring  a  little  water  into  the  tube  and  thus  dislodging  any  substance  which 
may  have  become  fixed  therein. 

After  the  accumulation  which  is  present  in  the  stomach  has  been 
siphoned  out  it  is  well  to  introduce  into  the  stomach  a  pint  of  normal  salt 
solution  at  100°  F.  and  then  siphon  it  out.  This  may  be  repeated  until  the 


256  GENERAL     SURGERY     OF     THE     ABDOMEN 

fluid  returns  clear.  It  is  well  in  these  cases  to  elevate  the  foot  of  the  bed 
about  thirty  inches  just  before  withdrawing  the  stomach  tube,  after  com- 
pleting gastric  lavage,  and  then  to  withdraw  the  tube  slowly.  In  this  manner 
it  is  possible  to  leave  the  stomach  completely  empty. 

The  Fowler  Position. 

The  patient  should  now  be  placed  in  bed  with  shoulders  somewhat 
elevated  so  as  to  favor  gravitation  toward  the  pelvis.  The  position  introduced 
by  Fowler,  which  is  accomplished  by  elevating  the  head  of  the  bed  twenty- 
four  to  thirty  inches,  seems  to  be  very  useful  in  these  cases,  and  we  have 
practised  placing  our  patients  in  this  position  constantly  since  Fowler  dem- 
onstrated its  value.  She  should  receive  absolutely  no  food  and  no  cathartics 
by  mouth.  Every  four  hours  she  should  have  an  enema  of  an  ounce  of  one 
of  the  concentrated  predigested  foods  dissolved  in  three  ounces  of  normal 
salt  solution.  We  are  confident  that  she  will  not  require  any  anodyne,  her 
pain  will  disappear  spontaneously,  since  we  have  removed  the  cause  of  ir- 
ritation by  performing  gastric  lavage.  It  is,  however,  perfectly  safe  after 
performing  gastric  lavage  to  give  the  patient  from  ten  to  thirty  drops  of 
deodorized  tincture  of  opium  in  each  rectal  feeding  until  the  pain  has  com- 
pletely subsided,  should  it  persist  after  the  gastric  lavage  has  been  com- 
pleted. This  would,  of  course,  be  extremely  harmful  were  any  food  or 
cathartics  to  be  given.  In  the  meantime  we  will  observe  the  patient  care- 
fully, because  it  is  quite  possible  that  a  circumscribed  abscess  may  develop 
in  the  right  inguinal  region.  If  this  should  occur  we  will  simply  drain  the 
abscess.  It  is  surprising  to  observe  how  much  infection  will  be  disposed  of 
by  the  peritoneum  and  the  omentum,  and  how  extensive  an  infection  of  the 
peritoneum  will  subside  completelv.  if  one  will  only  secure  a  condition  of 
rest  to  the  small  intestines  and  thus  prevent  the  further  infection  of  the 
portions  of  peritoneum  away  from  the  point  of  primary  infection  in  the 
vicinity  of  the  vermiform  appendix. 

Exceptionally  Unfavorable  Classes. 

There  are  two  classes  of  patients  in  whom  this  form  of  treatment  is 
not  so  satisfactory  as  it  is  in  all  other  classes,  namely,  the  very  old  and  the 
very  young.  Very  old  patients  do  not  bear  confinement  in  bed  well,  no 
matter  what  their  condition  may  be,  and  they  do  not  prosper  generally  on 
rectal  feeding.  In  these  cases  one  is  compelled  to  choose  between  two  evils, 
and  whichever  is  chosen  one  usually  wishes  it  had  been  the  other. 

It  should  be  stated  here  that  very  old  patients  bear  confinement  in  bed 
much  better  when  kept  in  the  Fowler  position  than  when  kept  in  the  hori- 
zontal position,  and  since  the  introduction  of  this  feature  we  have  never 
had  a  case  of  hypostatic  pneumonia  in  one  of  these  aged  patients  because  of 
their  confinement  to  bed. 

In  children  it  is  difficult  to  perform  gastric  lavage,  they  are  likely  to 
struggle  and  injure  themselves  while  this  is  being  accomplished.  The  same 
is  true  of  administering  rectal  feeding.  Moreover,  the  omentum  in  small 
children  is  not  sufficiently  developed  to  act  as  an  efficient  protection.  It  is 
consequently  wise  in  these  two  classes  to  operate  whenever  the  patient's 
condition  indicates  that  be  will  probably  recover  from  the  operation. 
Return  to  Diet. 

After  the  patient  has  recovered  from  the  acute  attack,  which  can  be 
determined  from  finding  the  temperature  and  pulse  normal,  the  diminished 


PLATE  XXI. 

ABDOMINAL    WOUND. 

Represents  the  next  step  in  the  closure  of  McBurney's  incision,  the  fascia  of 
the  internal  oblique  abdominal  muscle  having  been  united  with  a  continuous  cat-gut 
suture. 


PLATE  XXII. 

CLOSURE  OF  ABDOMINAL  WOUND. 

Represents  the  last  step  in  the  closure  of  McBurney's  incision,  the  deep  silkworm 
gut  sutures  and  the  coaptation  sutures  for  the  skin  having  been  applied. 


GENERAL     SURGERY     OF     THE     ABDOMEN  26 1 

rigidity  of  the  abdominal  wall,  pain  and  tenderness  upon  pressure  absent, 
the  obstruction  to  the  passage  of  gas  and  feces  relieved,  feeding  by  mouth 
may  be  commenced  gradually.  It  is  well  to  give  a  small  cup  of  beef  tea 
made  from  some  of  the  commercial  beef  extracts  every  three  hours  at  first, 
because  this  will  serve  to  encourage  the  patient,  while  it  will  not  give  rise  to 
peristaltic  motion  as  it  is  absorbed -from  the  stomach,  being  composed  almost 
entirely  of  non-irritating  soluble  substances.  Later  milk  and  lime-water, 
soups,  broth's  and  gruels  may  be  allowed.  We  believe  that  it  is  well  not  to 
operate  in  these  cases,  after  they  have  recovered  from  the  acute  attack,  until 
they  are  in  a  condition  in  which  it  seems  perfectly  safe  to  give  the  ordinary 
dose  of  castor  oil  which  we  are  in  the  habit  of  administering  in  preparing 
patients  for  abdominal  operations.  Of  course  this  should  not  be  given  so 
long  as  there  is  any  doubt  regarding  the  complete  recovery,  because  if  given 
too  early  it  might  be  the  cause  of  recurrence.  If  the  oil  causes  no  dis- 
turbance it  is  fair  to  suppose  that  the  patient  has  fully  recovered  from  the 
acute  attack  and  is  in  a  favorable  condition  for  obtaining  radical  relief. 

Many  patients  refuse  to  be  operated  after  they  have  recovered  from 
the  acute  attack,  and  until  the  past  few  years  we  frequently  had  a  patient 
come  under  our  care  on  the  third  to  the  seventh  day  of  an  attack  of  acute 
perforative  or  gangrenous  appendicitis  whom  we  would  treat  through  the 
acute  attack  with  the  method  just  described,  but  who  would  refuse  opera- 
tion during  the  interval.  Later  a  number  of  these  patients  had  recurrent  at- 
tacks and  were  treated  with  cathartics  or  were  operated  during  the  third 
or  fourth  day  of  a  severe  acute  attack  and  thus  lost  their  lives  unnecessarily. 
Later  Appendectomy. 

To  avoid  this  we  have  followed  the  plan  of  confining  these  patients  to 
liquid  diet  until  the  appendix  has  been  removed,  even  if  this  is  postponed 
for  several  months.  If  they  change  to  solid  food  they  usually  experience 
some  discomfort,  and  fearing  another  acute  attack,  have  returned  for  op- 
eration and  in  time  to  have  an  interval  operation. 

We  have  many  times  made  the  error  of  operating  too  soon  after  an 
acute  attack,  but  never  has  the  interval  been  too  long  in  cases  in  which  the 
patient  took  nothing  but  liquids,  together  with  soft  boiled  eggs,  mush, 
purees,  custards,  boiled  rice  and  thoroughly  cooked  cereals  after  recovering 
from  the  acute  attack  until  the  interval  operation  had  been  performed. 
Confirmatory  Testimony. 

Since  the  publication  of  the  second  edition  of  this  work,  thousands  of 
practitioners  of  medicine  and  surgery,  and  many  distinguished  surgeons 
who  were  not  convinced  of  the  correctness  of  our  views  concerning  this 
subject  at  that  time,  have  thoroughly  tested  the  method  and  have  either  pri- 
vately or  publicly  stated  that  by  add'ing  this  plan  to  their  former  conception 
of  the  indications  for  treatment  of  this  disease,  they  have  succeeded  in  re- 
ducing their  mortality  to  a  very  marked  extent. 

Our  own  experience  has  still  further  confirmed  the  correctness  of  the 
views  expressed  in  the  first  and  second  editions.  Circumstances  have  been 
such  that  we  have  had  an  opportunity  to  demonstrate  an  enormous  number 
of  these  cases  to  many  surgeons  from  all  parts  of  this  and  other  countries, 
so  that  at  the  present  time  we  need  but  repeat  the  indications  expressed  on 
this  subject  in  the  first  and  second  editions,  viz: 

Conclusions. 

In  order  that  our  views  concerning  the  treatment  of  appendicitis  may 


262  GENERAL     SURGERY     OF     THE     ABDOMEN 

be  perfectly  understood,  we  here  repeat  the  conclusions  which  were  formu- 
lated some  time  ago  and  which  have  been  followed  throughout  in  the  treat- 
ment of  all  of  our  cases. 

1.  The  mortality  in  appendicitis  results  from  the  extension  of  infec- 
tion from  the  appendix  to  the  peritoneum,  or  from  metastatic  infection  from 
the  same  source. 

2.  This  extension  may  be  prevented  by  removing  the  appendix  while 
the  infectious  material  is  still  confined  to  that  organ. 

3.  The  distribution  or  extension  of  the  infection  is  accomplished  by  the 
peristaltic  action  of  the  small  intestines. 

4.  It  is  also  accomplished  by  operation  after  the  infectious  material 
has  extended  beyond  the  appendix  and  before  it  has  become  circumscribed. 

5.  Peristalsis  of  the  small  intestine  can  be  inhibited  by  prohibiting-  the 
use  of  every  form  of  nourishment  and  cathartic  by  mouth  and  by  employ- 
ing gastric  lavage  in  order  to  remove  any  food  substances  or  mucus  from 
the  stomach. 

6.  The  patient  can  be  safely  nourished  during  the  necessary  period 
of  time  by  means  of  nutrient  enemata.     Large  enemata  should  never  be 
given,   for  they  may  cause  the  rupture  of  an  abscess  into  the  peritoneal 
cavity. 

7.  In  case  neither  food  nor  cathartics  are  given  from  the  beginning 
of  the  attack  of  acute  appendicitis,  and  gastric  lavage  is  employed,  the  mor- 
tality is  reduced  to  an  extremely  low  percentage. 

8.  In  cases   which  have  received  some   form  of   food  and   cathartics 
during  the  early  portion  of  the  attack,  and  are  consequently  suffering  from 
a  beginning  diffuse  peritonitis  when  they  come  under  treatment,  the  mor- 
tality will  still  be  less  than  four  per  cent,  if  peristalsis  is  inhibited  by  gastric 
lavage  and  the  absolute  prohibition  of  all  forms  of  nourishment  and  cathar- 
tics by  mouth. 

9.  In  this  manner  very  dangerous  cases  of  acute  appendicitis  may  be 
changed  into  relatively  harmless  ones  of  chronic  appendicitis. 

10.  In  our  personal  experience  no  case  of  acute  appendicitis  has  died 
in  which  absolutely  no  food  of  any  kind  and  no  cathartics  were  given  by 
mouth  from  the  beginning  of  the  attack. 

n.  The  mortality  following  operations  for  chronic  appendicitis  is 
exceedingly  low. 

12.  Were  peristalsis  inhibited  in  every  case  of  acute  appendicitis  by 
the  methods  described  above,  absolute  prohibition  of  food  and  cathartics  by 
mouth  and  the  use  of  gastric  lavage,  appendectomy  during  any  period  of  the 
attack  could  be  accomplished  with  much  greater  ease  to  the  operator  and 
correspondingly  greater  safety  to  the  patient. 

To  Reduce  the   Mortality  from  Appendicitis. 

The  following  suggestions  for  the  treatment  of  appendicitis  are  made 
with  a  view  of  reducing  the  mortality: 

T.  Patients  suffering  from  chronic  recurrent  appendicitis  should  be 
operated  on  during  the  interval. 

2.  Patients  suffering  from  acute  appendicitis  should  be  operated  on  as 
soon  as  the  diagnosis  is  made,  provided  they  come  under  treatment  while 
the  infectious  material  is  still  confined  to  the  appendix,  and  if  a  competent 
surgeon  is  available. 

3.  Aside  from  insuring  a  low  mortality  this  will  prevent  all  serious 
complications. 


GENERAL     SURGERY     OF     THE     ABDOMEN  263 

4.  In  all  cases  of  acute  appendicitis,  and  in  all  cases  of  peritonitis, 
without  regard  to  the  treatment  contemplated,  the  administration  of  food 
and  cathartics  by  mouth  should  be  absolutely  prohibited  and  large  enemata 
should  never  be  given. 

5.  In  case  of  nausea  or  vomiting,  or  gaseous  distention  of  the  abdo- 
men, gastric  lavage  should  be  employed. 

6.  In  cases  coming  under  treatment  after  the  infection  has  extended 
beyond  the  tissues  of  the  appendix,  especially  in  the  presence  of  beginning 
diffuse  peritonitis,   conclusions    four    (4)    and   five    (5)    should   always   be 
employed  until  the  patient's  condition  makes  operative  interference  safe. 

7.  In  case  no  operation  is  performed  neither  nourishment  nor  cathar- 
tics should  be  given  by  mouth  until  the  patient  has  been  free  from  pain  and 
otherwise  normal  for  at  least  four  days. 

8.  During  the  beginning  of  this  treatment  not  even  water  should  be 
given  by  mouth,  the  thirst  being  quenched  by  rinsing  the  mouth  with  cold 
water  and  by  the  use  of  small  enemata.    Later  small  sips  of  very  hot  water 
frequently  repeated  may  be  allowed,  and  still  later  small  sips  of  cold  water. 
There  is  danger  in  giving  water  too  freely,  and  there  is  great  danger  in  the 
use  of  large  enemata. 

9.  All  of  these  cases  are  greatly  benefited  by  the  use  of  continuous 
normal  salt  solution  by  rectum,  given  according  to  Murphy's  directions. 

10.  All  practitioners  of  medicine  and  surgery,  as  well  as  the  general 
public,  should  be  impressed  with  the  importance  of  prohibiting  the  use  of 
cathartics  and  food  by  mouth,  as  well  as  the  use  of  large  enemata,  in  cases 
suffering  from  acute  appendicitis  or  peritonitis. 

n.  It  should  be  constantly  borne  in  mind  that  even  the  slightest 
amount  of  liquid  food  of  any  kind  by  mouth  may  give  rise  to  dangerous 
peristalsis  and  may  change  a  harmless,  circumscribed  into  a  dangerous,  dif- 
fuse peritonitis. 

12.  The  most  convenient  form  of  rectal  feeding  consists  in  the  use  of 
one  ounce  of  any  of  the  various  concentrated  liquid  predigested  foods  in 
the  market,  dissolved  in  three  ounces  of  warm  normal  salt  solution,  intro- 
duced slowly  through  a  soft  catheter,  inserted  into  the  rectum  a  distance  of 
two  to  three  inches. 

13.  This  form  of  treatment  cannot  supplant  the  operative  treatment  of 
acute  appendicitis,  but  it  can  and  should  be  used  to  reduce  the  mortality  by 
changing  the  class  of  cases  in  which  the  mortality  is  greatest  into  another 
class  in  which  the  mortality  is  very  small  after  operation. 

14.  It  is  important  to  bear  in  mind  the  fact  that  this  treatment  is  al- 
ways indicated  without  regard  to  whether  an  immediate  operation  is  or  is 
not  contemplated. 

15.  It  is  further  important  not  to  be  deceived  by  the  very  rapid  im- 
provement of  what  appear  to  be  serious  cases  into  the  belief  that  the  case  is 
not  a  gangrenous   or  perforative  appendicitis,   because   such   patients   may 
easily  be  killed  by  giving  food  too  early. 

Diagnosis. 

In  order  to  treat  patients  suffering  from  appendicitis  with  the  greatest 
degree  of  success,  it  is  important  to  make  a  careful,  early  diagnosis.  This 
will  depend  upon  two  conditions : 

A  Careful  Physical  Examination. 

This  should  be  made  in  every  case  in  which  there  is  any  symptom  of 


264  GENERAL     SURGERY     OF     THE      ABDOMEN 

intra-abdominal  disturbance.  It  has  been  our  experience  to  find  that  a  mis- 
taken diagnosis  at  the  beginning  of  an  attack  of  appendicitis  has  usually  re- 
sulted from  the  fact  that  the  family  physician,  when  first  called,  was  willing 
to  make  a  diagnosis  of  gastritis,  or  enteritis,  or  catarrhal  disturbance  of  the 
alimentary  canal,  from  the  symptoms  given  by  the  patient  or  his  friends, 
without  himself  making  a  physical  examination  in  order  to  ascertain  the 
actual  state  of  affairs.  This  is  true  even  more  commonly  in  children  than  in 
adults.  Until  very  recently  more  than  ninety  per  cent,  of  all  cases  of  ap- 
pendicitis in  children  came  into  our  hospital  service  with  a  diagnosis  of  gas- 
tritis, and  more  than  fifty  per  cent,  had  not  been  subjected  to  a  physical  ex- 
amination. 

Only  a  few  years  ago  more  than  fifty  per  cent,  of  all  women  entering 
the  hospital  suffering  from  appendicitis  came  with  a  diagnosis  of  tubal 
infection.  This  error  was  so  common  at  that  time  that  many  of  the  best 
authors  upon  this  subject  of  appendicitis  stated  that  the  disease  occurred 
much  more  frequently  in  men  than  in  women.  (Deaver,  Fowler,  Mynter, 
etc.) 

A  careful  physical  examination  will,  of  course,  usually  eliminate  these 
errors,  and  will  enable  the  physician  to  prevent  the  patient  from  doing  things 
which  must  certainly  increase  the  gravity  of  the  disease,  and  which  un- 
doubtedly are  frequently  responsible  for  the  fact  that  the  correct  diagnosis 
is  not  made  until  the  patient  is  almost  or  quite  in  a  hopeless  condition.  We 
would  consequently  insist  upon  making  a  careful  physical  examination  in 
every  patient  the  first  and  most  important  step  toward  securing  proper  treat- 
ment in  cases  of  appendicitis. 

Clinical  Experience. 

Xothing  serves  ?o  well  to  aid  a  physician  in  comprehending  proper 
treatment  of  these  cases  as  the  observation  of  some  of  the  various  forms  of 
appendicitis  throughout  their  course,  and  especially  through  the  necessary 
operation.  This  is  true  particularly  of  physicians  practising  internal  medi- 
cine. One  can  really  not  have  a  clear  idea  of  the  behavior  of  a  diseased 
appendix  unless  he  has  observed  it  in  all  stages  of  disease  in  the  living  hu- 
man body.  It  is  such  a  natural  matter  to  imagine,  when  the  acute  condition 
subsides,  that  the  amount  of  disturbance  must  have  been  slight,  that  unless 
one  has  an  opportunity  later  to  demonstrate  the  actual  condition  by  re- 
moving the  appendix  he  is  not  likely  to  appreciate  the  gravity  of  the  disease 
in  ordinary  acute  cases. 

On  the  other  hand,  unless  one  has  observed  the  intra-abdominal  condi- 
tion during  the  acute  attack  in  some  of  the  most  desperate  cases  of  acute 
perforative  or  gangrenous  appendicitis,  in  which  the  removal  of  the  organ 
seemed  impossible  even  in  the  hands  of  the  most  skillful  surgeon,  and  a 
year  or  more  subsequently  at  a  second  operation  the  almost  normal  condition 
of  everything  within  the  abdominal  cavity,  with  the  exception  of  the  appen- 
dix itself  and  possibly  a  few  unimportant  adhesions,  he  is  hardly  competent 
to  appreciate  what  Nature  can  accomplish  within  the  peritoneal  cavity. 

In  order  to  become  familiar  with  these  pathological  conditions  we  be- 
lieve the  student  of  medicine  and  the  practitioner  doing  post-graduate  work 
should  observe  these  cases  before,  during  and  after  operation  in  the  great 
hospitals  where  such  examples  are  numerous,  and  they  should  study  the 
pathological  condition  in  the  living  patient.  In  the  study  of  these  processes 
in  the  living  patient  one  is  impressed  with  certain  facts  which  it  is  believed 
have  a  very  important  bearing  upon  the  treatment  of  appendicitis. 


GENERAL     SURGERY     OF     THE     ABDOMEN  265 

Drainage  of  the  Appendix. 

So  long-  as  the  appendix  is  in  a  condition  in  which  its  lumen  is  thor- 
oughly drained  the  organ  will  not  cause  any  serious  trouble,  and  just  in  the 
proportion  in  which  this  drainage  is  interfered  with  will  the  danger  to  the 
patient  increase. 

Primarily,  the  obstruction  is  always  due  to  an  inflammation,  either  di- 
rectly because  of  the  accompanying  congestion  or  edema,  which  in  itself 
may  suffice  to  obstruct  the  cecal  end  of  the  lumen ;  or  it  may  be  that  the 
first  infection  subsides  and  leaves  a  small  ulcer  which  heals  and  causes  a 
slight  amount  of  contraction,  and  at  the  time  of  the  next  acute  congestion 
or  inflammation  this  portion  of  the  lumen  is  already  abnormally  small  and 
consequently  the  more  easily  obstructed. 

The  moment  this  portion  of  the  lumen  becomes  completely  obstructed  a 
sudden  increase  in  the  infection  is  certain  to  occur,  and  this  will  constitute 
a  real  danger  to  the  patient.  Again,  in  many  cases  the  appendix  contains 
infected  granulation  tissue  for  a  considerable  period  of  time,  which  will  be 
in  a  condition  to  at  any  time  cause  an  obstruction  of  the  lumen  of  the  ap- 
pendix and  thus  be  favorable  to  the  production  of  serious  trouble. 

Whenever  an  infection  approaches  the  surface  of  the  appendix  the  lat- 
ter is  likely  to  become  adherent  to  the  surrounding  tissues,  and  this  in  turn 
results  in  an  obstruction  to  the  lumen  of  the  appendix  by  causing  short  bends 
or  kinks.  At  any  given  time  this  obstruction  may  become  so  complete  that 
nothing  will  drain  into  the  intestine,  and  then  there  is  grave  danger  of 
gangrene  of  the  organ  from  pressure  as  well  as  from  interference  with  the 
circulation.  There  is  the  same  difference  between  an  infected  appendix  with 
free  drainage  into  the  cecum,  and  one  in  which  this  drainage  has  been  ob- 
literated, that  we  find  in  an  acute  abscess  in  any  other  portion  of  the  body 
that  is  thoroughly  drained  and  one  in  which  no  drainage  has  been  estab- 
lished. 

The  increased  pressure  upon  the  tissues  surrounding  an  abscess  in  any 
portion  of  the  body  will  sooner  or  later  produce  pressure  necrosis,  and  this 
probably  accounts  for  gangrene  of  the  mucous  lining  of  severely  distended 
appendices  so  frequently  met  with  in  relatively  early  operation  in  severe 
cases  of  acute  appendicitis. 

Condition  of  Appendix  After  an  Acute  Attack. 

It  seems  most  important  to  impress  the  clinical  fact  upon  our  minds 
that  whatever  the  changes  may  be  which  occur  in  any  given  case  as  a  result 
of  acute  or  chronic  inflammation  of  the  appendix,  the  latter  is  rarely  in  as 
favorable  a  condition  as  regards  the  safety  of  its  possessor  after  as  before 
the  occurrence  of  this  inflammation.  The  change  in  its  structure  is  almost 
invariably  a  reduction  of  some  portion  of  its  lumen,  and  this  necessarily 
means  a  certain  degree  of  interference  with  its  drainage,  and  this  in  turn 
produces  a  tendency  to  the  recurrence  of  an  acute  or  chronic  inflammation. 

There  are  but  two  conditions  in  which  the  above  course  does  not  obtain : 
First,  in  the  rare  case  in  which  a  patient  recovers  from  an  acute  attack  in 
which  the  appendix  is  entirely  destroyed,  and.  second,  where  the  oblitera- 
tion of  the  lumen  begins  at  the  distal  end  of  the  organ  and  progresses  uni- 
formly toward  the  cecal  end.  This  is  also  exceedingly  rare. 

All  of  these  results  are  impressed  upon  the  surgeon  more  and  more 
forcibly  as  his  experience  increases,  and  it  seems  as  though  their  observa- 
tion should  lead  to  methods  of  treatment  which  would  be  more  and  more 
favorable  to  the  patient. 


266  GENERAL     SURGERY     OF     THE      ABDOMEN 

There  can  be  no  doubt  but  that  in  a  vast  majority  of  cases  a  vermiform 
appendix  which  has  once  been  the  seat  of  severe  inflammatory  disturbance 
can  never  thereafter  be  perfectly  normal. 

At  best,  the  normal  appendix  contains  conditions  very  favorable  for 
inflammatory  disturbances  from  the  fact  that  it  is  a  blind,  dependent  sac 
with  its  open  end  communicating  with  the  cecum,  which  normally  always 
contains  septic  material. 

Localization  of  the  Disease. 

While  so  much  can  be  said  against  this  organ,  yet  the  more  one  comes 
in  contact  with  it  the  more  points  will  he  find  which  seem  favorable  to  the 
patient  who  possesses  a  diseased  appendix  if  the  latter  is  removed  while  the 
infection  is  still  confined  to  its  lumen.  First,  there  is,  with  the  exception  of 
a  few  very  rare  instances,  always  a  time  in  every  case  of  appendicitis  when 
all  of  the  infectious  material  is  confined  to  this  organ  and  under  conditions 
which  are  favorable  to  removal  without  appreciable  interference  with  any 
other  organ.  Second,  the  appendix  is  in  an  accessible  region.  Third,  it  is 
easily  located  by  following  the  longitudinal  band  upon  the  surface  of  the 
cecum  in  a  downward  direction  until  it  is  found.  Fourth,  its  removal  from 
the  cecum  is  extremely  simple  and  when  once  removed  the  cecum  can  be 
left  smooth  and  without  any  denuded  surfaces.  In  other  words,  after  the 
appendix  has  been  removed  the  patient  is  in  no  way  physically  impaired. 
This,  however,  is  true  only  so  long  as  the  infection  is  still  confined  to  the 
appendix  itself,  a  condition  which  exists  during  the  very  beginning  of  an 
acute  attack,  and  after  a  patient  has  perfectly  recovered  from  an  acute  at- 
tack. This  being  the  case,  it  seems  logical  to  conclude  that  if  a  patient 
comes  under  care  during  a  time  when  he  is  in  this  condition,  it  will  be 
proper  to  relieve  him  of  this  useless  and  dangerous  organ. 

Time  Limit  of  Local  Infection. 

In  acute  appendicitis  no  definite  time  can  be  given  during  which  the 
infection  is  probably  still  within  the  appendix  itself,  but  in  severe  cases  this 
may  usually  be  accepted  as  during  the  first  thirty-six  hours  after  the  begin- 
ning of  an  attack.  In  mild  cases  this  condition  often  obtains  throughout  the 
entire  period  of  the  acute  attack.  It  is  consequently  important  to  use  one's 
judgment,  rather  than  to  go  by  any  number  of  hours,  in  determining  whether 
the  infection  is  still  within  the  appendix. 

It  is  quite  important,  however,  to  determine  this  fact,  because  if  one 
can  be  certain  thereof  he  can  also  be  certain  that  with  a  reasonable  amount 
of  skill  and  experience  in  abdominal  surgery  all  of  the  infectious  material 
may  be  removed  from  the  peritoneal  cavity  at  once,  leaving  the  latter  in 
an  exceedingly  favorable  condition  for  a  speedy  and  permanent  recovery. 

The  Determining  Condition  of  the  Immediate  Operation. 

All  surgeons  with  extensive  experience  in  the  treatment  of  appendicitis 
at  the  present  time  seem  to  agree  upon  this  one  view  :  That  in  acute  appen- 
dicitis, in  which  the  patient  comes  under  the  care  of  the  surgeon  during  a 
time  u'hcn  the  infection  is  still  confined  to  the  appendix,  an  immediate  op- 
eration is  indicated,  provided  a  competent  surgeon  is  available  and  the  other 
conditions  necessary  for  the  successful  execution  of  abdominal  operations 
arc  within  reach. 

This  is  true  for  the  following  reasons: 

i.     The  patient  is  practically  certain  to  recover. 


GENERAL     SURGERY     OF     THE     ABDOMEN  267 

2.  He  will  be  able  to  resume  his  occupation  within  a  short  time. 

3.  He  cannot  have  a  recurrence. 

4.  It  practically   eliminates   complications,   such  as   adhesions,   meta- 
static  abscesses,  empyema,  septic  endocarditis,  thrombo-phlebitis  and  peri- 
tonitis. 

5.  Drainage  will  be  unnecessary,  hence  there  is  no  danger  of  post- 
operative ventral  hernia. 

6.  The  infection  of  the  pelvic  organs  in  the  female,  with  their  serious 
consequences,  as  adhesions,  dysmenorrhea,  sterility,  ovarian  cyst,  etc.,  will 
be  avoided. 

7.  There  will  not  be  the  serious  digestive  disturbances  which  are  prac- 
tically always  present  in  patients  suffering  from  recurrent  appendicitis. 

8.  The  amount  of  suffering  will  be  reduced  to  a  minimum. 

Another  reason  which  is  commonly  mentioned  and  which  is  not  infre- 
quently given  in  favor  of  an  immediate  operation,  not  only  in  this  class  of 
cases,  but  in  all  cases  suffering  from  acute  appendicitis,  is  the  fact  that  we 
are  supposed  not  to  know  what  will  be  the  outcome  in  any  given  case  of  ap- 
pendicitis. This,  however,  is  true  only  in  cases  in  which  the  treatment  be- 
for  they  come  under  care  has  been  improper,  and  in  which  the  future  treat- 
ment is  likely  to  be  equally  bad. 

In  any  given  case  in  which  the  treatment  from  the  first  has  been  proper, 
and  in  which  it  will  be  equally  good  in  the  future,  we  can  predict  with  as 
much  certainty  as  in  any  disease  that  we  are  called  upon  to  treat  just  what 
the  future  will  bring.  This  is  true  because  of  the  peculiar  position  of  the 
appendix  and  because  of  its  environment. 

The  appendix  is  located  in  a  secluded  portion  of  the  peritoneal  cavity 
and  it  is  surrounded,  with  the  exception  of  the  inner  side,  by  relatively  fixed 
structures.  About  it  we  find  in  front,  the  cecum ;  to  the  outer  side  and  be- 
hind, the  abdominal  wall ;  below,  the  pelvic  cavity ;  and  only  to  the  inner 
side  have  we  the  exceedingly  movable  small  intestines.  Aside  from  this  we 
have  the  omentum.  which  is  always  ready  to  care  for  a  diseased  appendix 
by  placing  its  folds  about  the  latter  and  preventing  septic  material  from  in- 
fecting any  of  the  surrounding  structures. 

Nature's  Protective  Influences. 

Our  observations  have  been  convincing  beyond  a  doubt  that  the  tend- 
ency of  Nature  is  to  maintain  a  condition  of  rest,  and  thus  to  confine  the  in- 
fection to  this  secluded  portion  of  the  peritoneum.  Our  evidence  for  this 
conclusion  lies  in  the  following  facts : 

1.  The  ileo-cecal  valve  at  once  prevents  the  passage  of  gas  and  feces. 

2.  The  nausea  and  vomiting  results  in  the  expulsion  of  at  least  a  por- 
tion of  the  offending  intestinal  contents. 

3.  All  of  the  available  omentum  collects  about  the  appendix. 

4.  The  contraction  of  the  abdominal  muscles  over  the  appendix  limits 
motion  in  this  portion  of  the  abdominal  cavity. 

5.  The  right  thigh  is  frequently  flexed  to  enable  the  contraction  of 
the  iliacus  muscle  behind  the  appendix. 

6.  Whenever  the  abdomen  is  opened  in  cases  in  which  peristalsis  has 
been  inhibited  early  in  the  attack  by  making  gastric  lavage  and  then  giving 
neither  food  nor  cathartics  by  mouth,  the  appendix  is  found  virtually  sur- 
rounded by  parietal  peritoneum,  cecum.  cecal  end  of  ileum  and  omentum, 
and  thus  it  is  prevented  from  causing  trouble,  even  though  it  be  gangren- 


268  GENERAL     SURGERY     OF     THE     ABDOMEN 

ous  or  perforated.     Moreover,  we  have  observed  that  when  Nature  is  aided 

in  carrying-  out  this  tendency  to  establish  a  condition  of  rest,  it  will  result 

either  in  the  absorption  of  any  infectious  material  which  may  have  advanced 

beyond  the  tissues  of  the  appendix;  or,  if  this  be  no  longer  possible,  it  will 

result   in    the    formation   of   a    relatively    harmless,    circumscribed    abscess, 

which,  if  this  condition  of  rest  is  maintained,  will  practically  always  either 

perforate   into   the   cecum,    or   point   toward   the   anterior   abdominal    wall 

where  it  may  be  drained  easily  and  safely,  or  it  will  rupture  into  the  rectum. 

There  are  a  few  exceptions  to  this  rule  which  should  be  mentioned 

here.     In  very  emaciated  patients  with  almost  no  omentum,  and  in  young 

children  in  whom  the  omentum  is  often  very  slight,  this  organ  occasionally 

fails  to  supply  the  necessary  protection. 

It  should  be  stated  at  this  point  that  circumstances  have  made  it  pos- 
sible for  us  to  observe  an  unusually  large  number  of  cases  of  appendicitis, 
which  we  have  been  able  to  follow  through  the  acute  attack  and  later  been 
able  to  demonstrate  the  pathological  conditions  by  removing  the  appendix. 
We  should  also  state  that  in  every  case  in  which  it  was  possible  to  obtain  the 
consent  of  the  patient  we  have  removed  the  diseased  appendix  either  during 
the  acute  attack,  provided  the  patient's  condition  seemed  to  indicate  that  the 
operation  could  be  performed  safely ;  or  if  this  was  not  the  case,  to  remove 
the  appendix  in  the  interval  at  the  conclusion  of  the  acute  attack. 

Review  of  an  Extensive  Series  of  Cases. 

During  the  past  six  years  since  the  publication  of  the  following  statis- 
tics our  results  have  improved  very  greatly  for  several  reasons,  i.  Our  ex- 
perience has  been  vastly  increased  and  with  this  our  judgment  has  improved 
in  determining  the  conditions  which  in  turn  served  as  indications  to  details 
in  treatment.  2.  Practitioners  in  general  do  not  at  the  present  time  give 
cathartics  and  food  by  mouth  in  these  cases  as  they  did  formerly  when 
almost  every  patient  admitted  to  the  hospital  had  previously  received  both 
cathartics  and  food  by  mouth.  3.  We  admit  many  more  patients  within  the 
first  forty-eight  hours  after  the  beginning  of  the  attack.  4.  Our  operative 
technic  has  undoubtedly  improved  with  these  added  years  of  experience.  5. 
The  method  of  giving  normal  salt  solution  by  rectum  by  the  drop  method 
has  been  of  enormous  value. 

Instead  of  giving  the  newer  statistics  it  has,  however,  seemed  wise  to 
repeat  those  of  the  period  when  our  methods  were  on  probation  because  the 
lessons  from  the  blunders  made  during  this  period  seem  especially  valuable. 

In  preparing  the  preceding  edition  of  this  work  it  seemed  proper  to 
make  a  general  review  of  our  clinical  experiences  in  the  treatment  of  ap- 
pendicitis in  the  interval,  because  our  position  concerning  this  subject  at 
the  time  the  first  edition  appeared  did  not  correspond  with  that  held  by 
other  authors  at  that  time. 

In  order  to  substantiate  the  opinion  expressed  in  the  first  edition  of  this 
volume,  we  have  reviewed  all  the  histories  of  one  thousand  consecutive  cases 
of  appendicitis,  which  we  operated  at  the  Augustana  Hospital  during  the 
thirty-three  months  from  July  1,  1901,  to  April  I,  1904.  During  this  period 
of  time  every  patient  suffering  from  appendicitis  was  admitted,  at  any  time 
of  day  or  night,  without  regard  to  condition,  several  of  them  dying  almost 
immediately  upon  admission,  and  all  such  cases  are  included  in  these 
statistics. 

Of  the  cases  that  were  not  operated  only  those  who  died  were  counted 


GENERAL     SURGERY     OF     THE     ABDOMEN  269 

in  this  series  of  one  thousand,  because  in  those  who  recovered  from  the 
acute  attack,  but  were  not  operated,  it  was  impossible  to  determine  the  exact 
anatomical  diagnosis. 

On  the  other  hand,  it  was  necessary  to  count  the  cases  that  died,  but 
were  not  operated,  seven  in  all,  because  the  statistics  would  otherwise  not 
be  fair  in  comparison  with  those  of  other  surgeons,  who  might  have  op- 
erated these  fatal  cases.  We  would  say,  however,  that  with  possibly  one  or 
two  exceptions  these  seven  cases  were  quite  beyond  hope  when  they  entered 
the  hospital. 

The  number,  one  thousand,  was  chosen  because  of  the  convenience 
with  which  one  can  grasp  statistics  based  upon  multiples  of  ten.  The  last 
one  thousand  were  chosen  in  order  to  indicate  our  present  statistics.  They 
were  all  taken  from  the  Augustana  Hospital  records,  because  we  have  all  of 
the  cases  at  this  institution  under  personal  observation  every  day ;  while 
those  operated  at  other  hospitals  we  can  observe  less  constantly. 

CLASSIFICATION. 

Mortality. 
Percent- 
Cases.       Deaths.         age. 

Gironic  appendicitis  or  interval  operations 540  3  .5 

Acute  appendicitis  without  perforation 255  5  1.9 

(Of    these     six     entered     the     hospital     within 

thirty-six   hours   after   beginning   of    attack.) 

Acute    appendicitis,     perforated     or    gangrenous, 

without    abscesses 55  o  .o 

(Of  these  five  entered  the  hospital  within  for- 
ty-eight   hours    after    beginning    of    attack.) 

Acute  appendicitis,  perforated  with  abscess 117  4  3.4 

Acute   appendicitis   with    diffuse   peritonitis 33  10  30.0 


Total     i  ,000  22  2.2 

Of  the  255  acute  appendicitis  cases  without  perforation  200  were  op- 
erated upon  entering  the  hospital  and  55  were  treated  by  gastric  lavage  and 
absolute  prohibition  of  food  and  cathartics  of  every  kind  by  mouth,  the 
nutrition  being  accomplished  by  means  of  small  enemata.  Of  this  class  only 
six  cases  entered  the  hospital  within  thirty-six  hours  from  the  beginning  of 
the  attack. 

There  were  55  cases  in  which  there  was  a  gangrenous  or  perforated 
appendix,  which  were  admitted  before  an  abscess  had  formed.  Of  these 
there  were  five  who  entered  within  forty-eight  hours  after  the  beginning  of 
the  attack.  Of  the  entire  number  21  were  operated  at  once  and  34  were  first 
starved  until  they  seemed  in  a  safe  condition  for  operation.  In  most  of  these 
cases  the  appendix  was  completely  surrounded  by  the  omentum  and  held 
away  from  all  other  intra-abdominal  structures. 

Of  the  117  cases  of  acute  appendicitis,  perforative  or  gangrenous,  in 
which  an  abscess  had  formed,  39  were  operated  at  once  and  78  were  treated  by 
prohibition  of  all  nourishment  and  cathartics  by  mouth  until  their  condition 
seemed  sufficiently  improved  to  make  the  operation  appear  safe. 

Of  the  33  cases  entering  with  diffuse  peritonitis  resulting  from  perfora- 
tive or  gangrenous  appendicitis,  all  were  treated  at  first  with  gastric  lavage 


270  GENERAL     SURGERY     OF     THE     ABDOMEN 

and  exclusive  rectal  feeding.  Of  this  class  a  number  should  not  have  been 
admitted,  because  they  were  in  a  dying  condition  when  they  arrived  at  the 
hospital,  but  for  fear  of  excluding  any  case  which  might  recover,  notwith- 
standing its  apparently  hopeless  condition,  we  have  made  it  a  rule  never  to 
refuse  a  patient  suffering  from  any  acute  non-contagious  disease.  This  will 
account  for  what  we  believe  is  at  the  present  time  rather  too  high  a  mor- 
tality in  diffuse  peritonitis  due  to  perforative  or  gangrenous  appendicitis. 

Among  the  33  cases  belonging  to  this  class  there  were  seven  which 
were  not  operated,  because  they  were  in  a  dying  condition  when  they  entered 
the  hospital  or  because  from  the  time  of  admission  to  the  time  of  death  their 
condition  was  always  such  that,  with  previous  experience  with  similar  cases, 
operations  had  always  terminated  fatally.  Still  these  cases  were  counted 
among  our  deaths,  in  order  to  include  the  entire  mortality  of  all  the  cases 
treated. 

It  is  plain  that  if  these  cases  were  eliminated  and  the  cases  added  in 
which  recovery  followed  non-operative  treatment,  our  percentage  of  mor- 
tality would  be  reduced.  We  would  thus  have  only  15  cases  in  more  than 
1,000,  but  this  would  not  be  absolutely  fair,  because  it  might  be  argued 
that  the  death  in  at  least  some  of  these  seven  cases  should  be  attributed  to 
an  error  in  judgment,  and  that  if  even  the  apparently  absolutely  hopeless 
cases  bad  been  operated  at  once  some  of  them  might  have  recovered. 

Five  Hundred  and  Forty  Cases  of  Chronic  Appendicitis:  Three  Deaths. 

In  reviewing  the  histories  of  these  cases  we  find  many  interesting  facts. 
Among  the  three  deaths  in  five  hundred  and  forty  cases  of  chronic  appendi- 
citis with  interval  operations,  we  find  that  one  case,  a  weakly,  unmarried 
woman,  twenty-seven  years  of  age,  who  had  been  ill  much  of  the  time  dur- 
ing her  entire  life,  had  an  acute  attack  of  appendicitis  two  years  before  enter- 
ing the  hospital,  and  a  second  attack  one  year  ago,  since  which  time  she  had 
never  been  free  from  pain.  At  time  of  operation  the  appendix  was  found 
adherent,  13  cm.  long,  cicatricial  at  distal  end,  partially  obstructed  at  cecal 
end.  containing  small  amount  of  pus.  pelvis  secondarily  infected,  uterus  retro- 
verted  and  adherent,  together  with  ovaries  and  tubes  in  pelvis.  Tubes  closed 
at  distal  end  containing  small  amount  of  pus.  removed,  round  ligaments 
shortened.  No  drainage. 

Patient  died  four  weeks  after  operation  from  exhaustion,  probably  due 
to  absorption  from  raw  surface  in  pelvis.  Had  this  case  been  drained  she 
would  probably  have  recovered.  This  is  undoubtedly  also  true  if  only  the 
appendix  had  been  removed.  This  was  without  doubt  the  offending  organ, 
and  it  is  believed  that  its  removal  would  have  resulted  in  a  fair  recovery,  be- 
cause the  pelvic  organs  when  secondarily  infected  usually  show  great  re- 
cuperative powers  after  the  obstructed,  infected  appendix  has  been  removed. 

Case  2.  A  married  woman,  thirty-six  years  of  age,  having  suffered 
from  puerperal  infection  after  the  births  of  two  children,  thirteen  and  four- 
teen years  ago,  each  time  lasting  six  weeks ;  had  severe  attack  of  acute 
appendicitis  twelve  and  a  half  years  ago,  confining  her  to  bed  for  three 
weeks.  Since  this  time  she  has  constantly  suffered  from  subacute  appendi- 
citis. 

At  the  time  of  the  operation  patient  was  in  a  greatly  reduced  condition. 
The  appendix  was  club-shaped  at  distal  end  and  almost  completely  oc- 
cluded at  cecal  end.  and  contained  several  hard  fecal  concretions.  This 
was  removed  and  also  both  tubes  and  ovaries,  which  were  adherent  in  the 
pelvis,  probably  as  a  result  of  the  puerperal  infection.  No  drainage  was 


GENERAL     SURGERY     OF     THE     ABDOMEN  2/1 

established.  The  patient  died  on  the  fifteenth  day  after  the  operation  from 
exhaustion.  The  same  error  in  treatment  accounted  for  the  death  of  this 
patient  as  of  the  previous  one. 

In  patients  who  have  been  greatly  reduced  by  long-continued  disease 
it  is  not  wise  to  operate  too  extensively,  and  if  this  is  done  drainage  should 
be  used  in  order  to  relieve  the  patient  of  the  burden  resulting  from  the 
necessity  of  absorbing  the  secretion  from  denuded  surfaces. 

Case  3.  In  this  patient,  a  woman  thirty-four  years  of  age,  the  chronic 
appendicitis  existing  for  a  period  of  nine  years  was  complicated  by  double 
pyosalpinx.  Both  tubes,  the  right  ovary  and  the  appendix,  were  removed. 
The  appendix  was  18  cm.  long,  acutely  flexed  about  its  middle  by  an  ad- 
h"sion  to  the  cecum.  The  distal  end  contained  mucus  and  fecal  matter. 

The  patient  showed  symptoms  of  intra-abdominal  hemorrhage  four 
hours  after  the  operation.  She  was  reopened  hurriedly  and  it  was  found 
that  the  ligature  upon  the  severely  congested  right  broad  ligament  had  cut 
though  the  ovarian  artery  and  the  patient  succumbed  to  the  loss  of  blood. 

The  husband  of  this  patient  was  at  the  same  time  under  treatment  by  a 
colleague  for  specific  urethritis.  It  is  consequently  plain  that  the  infection 
of  the  tubes  was  not  due  to  the  appendicitis. 

This  death  was  due  to  an  avoidable  accident. 

The  three  deaths  in  this  group  would  have  been  avoided  had  the  opera- 
tion been  confined  to  the  removal  of  the  diseased  appendix.  The  amount  of 
disease  found  in  the  tubes  seemed,  however,  at  the  time,  to  indicate  their  re- 
moval. 

Ordinarily  in  similar  statistics  none  of  these  cases  would  be  included  in 
deaths  resulting  from  appendicitis  operations  because  the  appendicitis  op- 
eration had  no  relation  to  the  deaths,  but  in  these  statistics  every  case  is 
counted  in  which  the  appendix  was  removed  during  this  period  of  time  even 
though  the  other  disease  for  which  the  patient  was  operated  at  the  same 
time  was  by  far  the  more  serious  condition. 

A<~nte  Appendicitis  Without  Perforation:  255  Cases,  5  Deaths. 

Case  i.  Married  woman,  forty-eight  years  old,  four  pregnancies,  two 
abortions.  Has  had  many  slight  attacks  of  appendicitis  during  past  five 
years,  accompanied  by  severe  pain,  lasting  from  two  to  five  hours.  Last 
night  had  an  attack  more  severe  than  any  previous  one.  Suffers  severe  pain 
over  region  of  appendix  of  a  diffuse  character  when  it  commenced.  Ab- 
dominal walls  very  thick,  making  palpation  impossible.  Operation  at  once, 
because  it  seemed  likely  that  the  infection  would  be  found  confined  to  the 
appendix.  The  appendix  was  found  universally  adherent  behind  the  cecum, 
partly  surrounded  by  the  omentum.  It  was  removed  with  difficulty,  neces- 
sitating a  considerable  amount  of  manipulation  of  the  cecum  and  the  omen- 
tum. No  drainage. 

The  patient  died  of  peritonitis  on  the  tenth  day  after  the  operation, 
probably  due  to  the  traumatism  necessary  in  the  removal  of  the  deeply 
buried  appendix,  together  with  infection  from  the  acutely  inflamed  organ. 

Had  this  patient  been  starved  during  the  acute  attack  and  operated 
in  the  interval  she  would  probably  have  recovered. 

Case  2.  This  patient,  an  emaciated  man  forty-four  years  of  age,  en- 
tered the  hospital  at  the  end  of  an  acute  attack,  which  had  not  been  very  se- 
vere. He  had  suffered  from  recurrent  attacks  of  appendicitis  at  various  in- 
tervals for  a  period  of  about  twenty  years.  The  last  three  attacks  had  been 
more  severe  and  he  was  unable  to  recuperate  from  them.  Operated  at  once 


272  GENERAL     SURGERY     OF     THE     ABDOMEN 

and  found  a  severely  congested  appendix,  club-shaped  at  the  distal  end  and 
constricted  at  the  cecal  end.  It  was  universally  adherent  to  the  lower  end 
of  the  cecum  and  the  distal  end,  which  contained  a  small  amount  of  pus,  was 
adherent  to  the  anterior  surface  of  the  iliacus  muscle. 

The  appendix  was  dissected  out  and  the  wound1  closed.  The  patient 
died  on  the  seventh  day  from  peritonitis.  The  autopsy  showed  a  small 
amount  of  cloudy  fluid  in  the  pelvis.  The  infection  had  started  from  the 
tissues  to  which  the  club-shaped  end  of  the  appendix  had  been  adherent, 
having  evidently  extended  through  the  walls  of  the  appendix  during  the  late 
acute  attack.  This  death  could  have  been  avoided  by  proper  drainage.  It  is 
to  be  charged  to  faulty  technique. 

Case  3.  Is  interesting  because  quite  unusual.  A  strong  laborer,  twen- 
ty-four years  of  age,  had  an  acute  attack  of  appendicitis  one  month  ago 
which  lasted  one  week.  Within  two  days  there  had  been  a  slight  recurrence, 
but  it  seemed  likely  that  infection  was  confined  to  the  appendix. 

The  operation  showed  a  congested,  edematous  appendix  coiled  upon 
itself  like  a  snail,  adherent  between  the  lower  end  of  the  cecum  and  the 
mesentery  of  the  ileum,  obstructed  at  its  cecal  end  and  containing  pus  and 
feces  in  its  distal  end.  Abdomen  closed  without  drainage. 

On  the  third  day  after  operation  there  developed  a  pneumonia,  which 
progressed  in  a  mild  form  until  the  patient  suddenly  contracted  a  pneumo- 
coccus  peritonitis,  of  which  he  died  on  the  seventeenth  day  after  operation. 

The  anesthesia  had  been  started  with  chloroform,  which  was  changed 
to  ether  just  before  beginning  to  operate  and  continued  with  ether  through- 
out. 

Pneumonia  is  much  more  likely  to  occur  in  cases  wherein  the  alimen- 
tary canal  has  not  been  thoroughly  emptied  by  a  cathartic,  hence  it  is  likely 
that  this  patient  would  not  have  died  had  we  waited  to  do  an  interval  op- 
eration. 

Case  4.  A  farmer,  thirty-four  years  old,  entered  the  hospital,  giv- 
ing a  history  of  rather  a  severe  acute  attack  of  appendicitis  one  month  pre- 
vious, from  which  he  had  recovered  in  one  week  with  the  exception  of 
marked  tenderness  and  some  pain  over  McBurney's  point.  His  temperature 
was  normal  and  his  pulse  sixty-six  beats  per  minute.  He  was  otherwise 
normal. 

The  appendix  was  universally  adherent  behind  the  cecum,  was  ob- 
structed at  the  cecal  end  and  contained-  bloody  pus ;  it  was  ninteen  centi- 
meters long  and  its  distal  end  reached  nearly  up  to  the  liver.  The  denuded 
surface  was  covered  with  peritoneum  and  the  abdomen  closed  without  drain- 
age. The  patient  died  five  days  after  the  operation  from  acute  peritonitis. 

Drainage  would  have  prevented  this  death.  Dissecting  out  so  long  an 
appendix  containing  pus,  before  the  acute  attack  had  completely  subsided, 
without  instituting  drainage,  we  think  showed  bad  judgment. 

Whenever  there  is  the  slightest  doubt  in  any  case  about  requiring 
drainage  it  should  be  the  rule  to  drain.  In  other  words,  when  absolutely 
certain  that  drainage  is  not  needed,  close  without  drainage;  when  in  doubt 
at  all,  drain. 

Case  5.  A  boy  fifteen  years  of  age  became  ill  with  typhoid  fever  eight 
weeks  before,  which  lasted  five  weeks ;  was  apparently  well  two  weeks  ago. 
Ten  days  ago  developed  slight  fever  and  was  confined  to  bed  for  three 
days ;  then  he  was  apparently  well  until  ten  hours  before  he  was  brought 
to  the  hospital,  when  he  developed  excruciating  pains  over  the  entire  ab- 


GENERAL     SURGERY     OF      THE     ABDOMEN  273 

domen,  which  became  more  severe  in  the  region  of  the  appendix.  When  the 
family  physician  was  called  he  found  the  boy  writhing  in  pain  lying  upon 
the  floor.  He  immediately  sent  him  to  the  hospital  with  a  diagnosis  of 
probable  perforation  of  typhoid  ulcer,  with  a  possible  diagnosis  of  acute  ap- 
pendicitis. 

The  patient  was  at  once  anesthetized  with  chloroform,  then  ether  was 
given  throughout  the  operation,  wrhich  lasted  but  twenty  minutes.  The  ap- 
pendix was  found  edematous,  congested,  the  size  of  a  finger.  It  was  re- 
moved. Its  walls  were  very  thick,  its  lumen  was  occluded  at  the  cecal  end 
by  the  edematous  mucous  membrane ;  the  mucous  membrane  of  the  ap- 
pendix was  gangrenous  in  a  number  of  circumscribed  spots  one  centimeter 
in  diameter. 

The  patient  had  uremic  convulsions  almost  at  once  upon  recovering 
from  the  anesthetic,  which  became  more  and  more  frequent,  notwithstanding 
the  use  of  hot  air  baths  and  transfusion  of  normal  salt  solution.  Just  before 
he  was  anesthetized  he  had  a  slight  convulsion,  which  was  supposed  to  be 
the  result  of  his  severe  suffering,  but  which  was  probably  uremic. 

In  this  case  the  indications  for  immediate  operation  were  so  strong 
that  it  is  doubtful  whether  one  could  have  improved  upon  the  treatment, 
but  this  is  the  only  case  in  this  group  of  five  that  probably  could  not  have 
been  saved  with  proper  care,  and  even  in  this  case,  it  may  have  been  bad 
judgment  to  undertake  operation  so  soon  after  his  recovery  from  typhoid 
fever.  Had  we  placed  him  on  proctoclysis  by  the  drop  method  and  pro- 
hibited all  nourishment  by  mouth,  he  would  probably  have  recovered.  In 
each  one  of  the  preceding  four  cases,  the  death  was  undoubtedly  due  to  bad 
surgical  judgment  or  bad  technique. 

CONCLUSIONS. 

All  of  these  patients  were  operated  immediately  upon  entering  the  hos- 
pital because  their  condition  seemed  to  indicate  that  the  infectious  material 
was  confined  to  the  appendix.  Had  these  five  cases  been  added  to  the  fifty- 
five  cases  of  this  group  in  which  gastric  lavage  was  employed,  and  which  re- 
ceived neither  food  nor  cathartics  by  mouth,  but  were  confined  to  exclusive 
rectal  feeding,  it  is  likely  that  three  or  possibly  four  might  have  recovered. 
This  favorable  outcome  might  also  have  been  secured  had  drainage  been 
instituted. 

The  total  result  of  less  than  two  per  cent,  mortality  in  this  group  of 
255  cases  of  acute  appendicitis  is,  of  course,  eminently  satisfactory,  but  with 
the  addition  of  the  above  criticism,  it  is  believed  that  results  in  a  correspond- 
ing group  of  the  same  number  of  similar  cases  we  can  look  for  a  further 
reduction  in  the  mortality.  (This  prediction  was  made  more  than  six  years 
ago  and  our  experience  since  that  time  has  proven  the  correctness  of  the 
statement.) 

Acute   Perforative   or  Gangrenous   Appendicitis  Without   Abscess:   55   Cases,   No 
Deaths. 

The  next  group  L  especially  interesting,  because  it  contains  fifty-five 
cases  in  which  the  app^dix  was  completely  surrounded  by  omentum  and  in 
which  this  protection  was  so  effective  that,  notwithstanding  the  presence  of 
grangrene  or  perforation,  the  infectious  material  had  remained  perfectly 
circumscribed.  In  all  of  these  patients,  without  regard  to  the  contemplated 


2/4  GENERAL     SURGERY     OF     THE     ABDOMEN 

treatment,  food  by  the  mouth  and  cathartics  were  prohibited  at  once  upon 
admission  to  the  hospital,  gastric  lavage  was  employed,  exclusive  rectal  feed- 
ing was  instituted  and  continued  for  one  week  or  longer,  in  fact  until  they 
were  normal  as  regards  temperature,  pulse  and  pain  in  the  region  of  the  ap- 
pendix. Five  of  these  cases  entered  the  hospital  within  forty-eight  hours 
after  the  beginning  of  the  attack  and  were  operated  at  once.  Sixteen  of  the 
remaining  cases  seemed  in  a  condition  making  an  immediate  operation  safe 
and  were  operated  at  once.  The  remaining  thirty-four  cases  were  placed 
upon  exclusive  rectal  feeding  until  their  meteorism,  pain  and  temperature  had 
disappeared  and  their  general  condition  had  improved  to  the  point  at  which 
it  seemed  safe  to  perform  the  operation.  This  occurred  in  most  cases  within 
four  days  after  admission,  while  in  others  the  interval  was  longer. 

In  this  group  of  cases  there  is  much  danger  of  supposing  that  a  wrong 
diagnosis  had  been  made  primarily,  and  that  it  would  be  safe  to  give  at 
least  liquid  food  and  possibly  cathartics  as  soon  as  the  patient  became  appar- 
ently normal.  We  are  certain  that  this  error  has  cost  a  number  of  lives  and 
has  been  responsible  for  many  serious  recurrences. 

The  condition  is  not  as  rare  as  one  might  suppose,  as  55  cases  in  a 
group  of  1,000  makes  5.5  per  cent. 

Acute  Perforative  or  Gangrenous  Appendicitis  with  Peritonitis  and  Abscess:  117 
Cases,  4  Deaths. 

All  of  these  patients  entered  the  hospital  after  the  third  day  from  the 
beginning  of  the  attack.  They  had  all  received  some  form  of  food  before 
admission,  and  most  of  them  had  received  cathartics. 

Quite  a  proportion  of  these  cases  stated  that  they  had  received  no  food 
of  any  kind,  but  when  questioned  specifically  as  to  whether  they  had  not  re- 
ceived either  milk  or  broth  or  soup,  every  one  that  had  previously  affirmed 
that  no  food  at  all  had  been  taken  admitted  that  one  or  the  other  of  these 
forms  of  nourishment  had  been  given  them. 

Many  of  these  patients  were  received  in  a  desperate  condition,  with 
what  seemed  at  first  to  be  diffuse  peritonitis,  severe  distension  of  the  abdo- 
men, which  was  perfectly  tense,  nausea  and  vomiting.  The  slightest  jar  of 
the  bed  would  cause  severe  distress.  Many  of  them  had  a  bad  facial  ex- 
pression and  seemed  to  be  in  a  condition  of  shock  with  cold  perspiration 
over  the  forehead. 

It  is  in  this  class  of  cases  that  we  formerly  had  a  large  mortality, 
which  is  still  shared  by  all  surgeons  who  operate  at  once  in  every  case  of 
acute  appendicitis  immediately  upon  making  the  diagnosis. 

These  were  classed  by  Mynter  as  beginning  diffuse  peritonitis.  Per- 
sonally we  had  considered  them  as  belonging  to  a  class  in  which  the  primary 
diagnosis  of  severe  peritonitis  was  incorrect,  as  proven  by  the  fact  that  the 
abscess  later  became  circumscribed ;  but  a  study  of  the  excellent  work  of 
Moszkowicz  seems  to  prove  beyond  a  doubt  that  the  peritoneum  in  these 
cases  has  a  sufficient  amount  of  resistance  to  change  an  early  diffuse  into  a 
late  circumscribed  peritonitis. 

Absorption  of  Poisonous  Intestinal  Products. 

One  very  important  point  has  not  received  sufficient  appreciation  here — 
namely,  that  the  verv  bad  general  condition  of  the  patient  is  greatly  exag- 
gerated by  the  fact  that  a  great  amount  of  decomposing  substance  is  being 
absorbed  from  the  stomach  and  small  intestines,  which  would  in  itself 
suffice  to  make  an  otherwise  perfectly  healthy  person  extremely  ill. 


GENERAL     SURGERY     OF     THE     ABDOMEN  275 

The  excellent  studies  of  Maury  have  demonstrated  that  this  view  is  ab- 
solutely correct ;  that  there  is  indeed  secreted  from  the  lining  of  the  duo- 
deuum  in  these  cases  an  exceedingly  poisonous  substance,  consequently  the 
benefit  which  we  had  demonstrated  empirically,  has  now  been  confirmed 
scientifically.  These  patients  give  one  the  impression  of  having  been  pois- 
oned so  long  as  the  decomposing  substance  remains  in  the  stomach. 

In  these  cases  the  localized  inflammation  in  the  region  of  the  appendix 
prevents  the  elimination  of  the  contents  of  the  stomach  and  the  small  intes- 
tines through  the  rectum,  and  thus  decomposition  is  greatly  increased,  as 
there  is  no  natural  drainage.  In  most  of  them  we  have  found  that  just 
enough  food  is  placed  in  the  stomach,  suited  for  decomposition,  to  produce 
the  worst  possible  conditions.  It  would  be  as  reasonable  to  suppose  that  a 
person  would  not  be  in  danger  of  drowning  if  he  were  submerged  beneath 
but  a  small  amount  of  water,  as  to  suppose  that  small  amounts  of  liquid 
nourishment  given  by  mouth  are  harmless,  when  one  fully  comprehends 
existing  influences. 

This  is  still  further  favored  by  the  foolish  idea  that  there  can  be  nothing 
left  in  the  stomach  because  the  patient  has  vomited  incessantly  for  a  number 
of  hours.  In  many  of  the  cases  where  vomiting  has  continued  persistently 
for  hours  we  have  removed  great  quantities  of  decomposing  material,  in 
fact,  apparently  enough  to  hopelessly  poison  a  healthy  person. 

Upon  removing  this  material  by  gastric  lavage  we  have  seen  many  pa- 
tients improve  in  a  remarkable  way.  Frequently  the  temperature  will  be- 
come normal,  or  nearly  so,  within  forty-eight  hours,  the  pulse  reduced  from 
one  hundred  and  twenty  beats,  or  more,  to  one  hundred,  or  less,  per  minute. 
The  nausea  and  vomiting  will  disappear  after  one  or  two,  or  at  most  three, 
gastric  lavages,  the  tympanitis  will  be  greatly  reduced,  and  not  uncommonly 
it  will  be  possible  to  outline  a  swelling  in  the  region  of  the  appendix. 

Probably  it  will  never  be  possible  to  treat  this  class  of  cases  entirely 
without  mortality,  but  with  the  method  we  have  employed  the  mortality  has 
been  reduced  to  less  than  3.5  per  cent.  The  deaths  in  this  class  occurred  in 
the  following  four  cases:  (Since  this  was  written  six  years  ago  our  mor- 
taility  in  this  class  of  cases  has  been  reduced  to  less  than  two  per  cent.) 

Case  i.  A  well-nourished  man,  thirty-two  years  of  age,  with  a  good 
history,  with  the  exception  of  some  apparently  unimportant  digestive  dis- 
turbances, which  were,  however,  probably  referable  to  a  chronic  appendicitis, 
entered  the  hospital  on  the  fifth  day  of  an  acute  attack.  Patient  received  no 
food  from  the  beginning  of  the  attack  and  no  cathartics  during  the  first 
two  days  ;  on  the  third  and  fourth  days  some  liquid  food  was  given,  and  on 
the  fourth  day  a  dose  of  calomel  was  administered.  Patient  did  very  well 
during  the  first  two  days,  suffered  a  little  more  during  the  third  day  and 
became  violently  ill  twenty  hours  after  the  administration  of  calomel. 

On  admission  temperature  was  103  degrees  F.  and  the  pulse  94.  He 
suffered  severe  pain  in  the  right  inguinal  region,  the  abdomen  was  severely 
distended  with  gas  and  a  mass  could  be  palpated  in  the  right  inguinal  region. 
The  patient's  facial  expression  was  bad  and  it  seemed  as  though  the  peris- 
talsis caused  by  the  administration  of  the  calomel  had  produced  an  extension 
of  the  previously  circumscribed  peritonitis,  but  as  there  was  evidently  an 
abscess  present,  immediate  operation  was  performed. 

An  incision  twelve  centimeters  in  length  through  the  right  rectus  ab- 
dominis  muscle  evacuated  nearly  a  litre  of  foul  pus.  The  abscess  was  freely 
drained  with  two  glass  drainage  tubes  and  with  iodoform  gauze,  without 


276  GENERAL     SURGERY     OF     THE     ABDOMEN 

making-  an  attempt  at  removing-  the  appendix.     Death  occurred  three  days 
later  from  peritonitis. 

In  this  case  it  seems  clear  that  the  diffuse  infection  was  due  to  the  peris- 
talsis caused  by  the  administration  of  calomel  on  the  fourth  day  of  the  at- 
tack. It  may  have  been  bad  practice  to  operate  at  once,  but  at  the  time  it 
seemed  proper.  This  death  must,  of  course,  be  charged  to  the  murderous 
use  of  cathartics  in  acute  appendicitis. 

Case  2.  A  somewhat  emaciated  boy,  fourteen  years  of  age,  entered 
the  hospital  on  the  twelfth  day  after  the  beginning  of  his  attack.  During 
the  first  six  days  the  attack  was  mild  and  he  received  food  by  mouth.  During 
the  last  six  days  he  had  received  only  a  small  amount  of  liquid  nourishment 
by  mouth.  Temperature,  102.2  degrees  F.  Pulse,  100.  Patient  appeared 
very  weak  and  ill,  his  abdomen  was  distended  with  gas.  For  the  first  five 
days  after  admission  exclusive  rectal  feeding  was  employed  and  the  infec- 
tion became  circumscribed  in  the  right  iliac  region,  reaching  a  little  beyond 
the  median  line  to  the  left.  An  incision  ten  centimeters  long  \vas  made 
through  the  right  rectus  abdominis  muscle.  The  appendix  was  found  per- 
forated at  distal  end.  It  was  surrounded  by  the  cecum,  the  ileum  and  the 
omentum.  The  perforation  in  the  end  communicated  with  an  abscess  con- 
taining several  ounces  of  pus,  which  was  carefully  evacuated  by  sponging, 
then  the  appendix  separated  from  its  adhesions  and  removed,  which  in  this 
case  was  undoubtedly  the  fatal  mistake.  The  abscess  cavity  was  drained. 
The  patient  died  of  peritonitis  two'  days  later. 

Had  we  used  better  judgment  in  this  case  by  simply  draining  the  abscess 
and  removing  the  appendix  later  on  in  the  interval,  the  patient  would  prob- 
ably have  recovered. 

The  additional  time  consumed,  the  increased  trauma  and  the  exposure 
of  abraded  surfaces  in  a  patient  with  slight  resistance  could  scarcely  have 
resulted  differently.  Furthermore,  had  this  patient  received  neither  food 
nor  cathartics  by  mouth  from  the  beginning  of  his  attack  he  would  un- 
doubtedly not  have  lost  his  life. 

Case  3.  A  boy  six  years  of  age  entered  the  hospital  on  the  seventh  day 
of  an  apparently  mild  attack  of  acute  appendicitis.  During  the  preceding 
three  years  the  patient  frequently  complained  of  colicky  pains,  followed  by 
vomiting.  These  attacks  never  lasted  more  than  twenty-four  hours. 

The  patient  had  received  liquid  diet  throughout  the  present  attack.  The 
right  thigh  was  flexed  upon  the  abdomen  and  in  the  region  of  the  appendix 
a  mass  could  be  felt.  The  abdomen  was  moderately  distended  with  gas,  the 
abdominal  muscles  over  the  appendix  were  tense.  Temperature,  101  de- 
grees F. ;  pulse,  100. 

The  patient  was  placed  on  exclusive  rectal  feeding  for  forty-eight  hours, 
when  the  abdomen  was  flat,  the  pain  had  disappeared  except  directly  over  the 
appendix.  Temperature,  99  degrees  F.  ;  pulse,  90. 

An  incision  six  centimeters  long  through  the  right  rectus  abdominis 
muscle  exposed  an  abscess  containing  about  one  ounce  of  pus  and  a  thick, 
club-shaped  appendix  perforated  at  the  end.  The  appendix  was  adherent  to 
the  anterior  surface-  of  the  iliacus  muscle  and  the  abscess  was  completely 
surrounded  by  the  omentum,  cecum  and  ileum.  The  pus  was  sponged  away 
without  soiling  any  tissue,  the  appendix  removed  and  the  abscess  cavity 
drained  with  iodoform  gauze  and  with  a  glass  tube. 

The  patient  progressed  normally  for  twenty-four  hours,  when  he  died 
suddenly  without  any  apparent  cause.  An  autopsy  was  not  obtainable. 


GENERAL     SURGERY     OF      THE     ABDOMEN  2/7 

One  can  never  hope  to  eliminate  entirely  such  instances  of  death.  The 
conditions  appeared  very  favorable  for  a  rapid  and  complete  recovery  and 
there  seemed  to  be  no  reason  for  expecting  a  fatal  result. 

In  one  case  of  sudden  death  a  number  of  years  ago,  after  an  operation 
for  appendicitis  in  which  the  appendix  was  attached  to  the  iliac  vein,  the 
result  occurred  from  the  loosening  of  a  thrombus  of  the  external  iliac  vein. 
It  is  possible  that  the  same  accident  happened  in  the  present  case. 

Case  4.  A  woman  fifty-five  years  of  age,  who  entered  the  hospital 
with  a  fistula  of  the  cectim  due  to  an  acute  perforative  appendicitis,  operated 
elsewhere  three  months  previously. 

The  patient's  condition  was  satisfactory  after  the  operation,  which  con- 
sisted in  the  closure  of  a  fecal  fistula  in  the  cecum  three  centimeters  long. 
Five  weeks  after  the  operation,  before  the  drainage  wound  had  completely 
healed,  but  after  the  patient  had  been  out  of  bed  for  one  week,  she  suddenly 
developed  gangrene  of  the  right  lung,  from  which  she  died  a  week  later. 

This  condition  undoubtedly  resulted  from  an  infarct  due  to  a  thrombus 
formed  as  a  result  of  the  disease  or  the  operation,  but  wre  have  been  unable 
to  trace  the  connection,  as  an  autopsy  was  not  granted. 

Concerning  the  operations  in  all  of  these  cases  we  have  invariably  en- 
deavored to  reduce  the  traumatism  to  a  minimum.  The  surrounding  perito- 
neal cavity  has  been  protected  with  warm,  moist  gauze  pads.  All  unneces- 
sary manipulations  were  avoided.  In  case  of  circumscribed  abscess  the  ap- 
pendix was  removed  when  it  seemed  as  though  this  could  be  accomplished 
safely.  The  above  histories  show  that  several  errors  of  judgment  occurred 
in  connection  with  this  feature  in  this  series. 

Drainage  was  used  whenever  it  seemed  as  though  the  peritoneum  might 
not  be  capable  of  disposing  of  any  infection  remaining.  In  this  again  there 
were  some  fatal  errors.  It  is  much  better  to  drain  too  often  than  to  err  in  the 
opposite  direction. 

Irrigation  was  not  employed  in  any  of  these  cases  because  our  experi- 
ence has  been  less  satisfactory  when  this  means  was  frequently  employed. 

Reiteration  of  Cardinal  Principles  of  Treatment. 

It  is,  of  course,  impossible  to  go  more  fully  into  the  histories  in  so  large 
a  series  of  cases  without  making  the  report  unduly  long  and  correspondingly 
tedious.  We  believe,  however,  that  enough  has  been  said  to  make  it  plain 
that  experience  with  this  series  of  one  thousand  consecutive  cases,  whose 
treatment  was  based  upon  the  conclusions  previously  given,  would  justify 
us  in  urging  others  to  make  use  of  the  same  principles  in  treating  similar 
cases. 

To  those  who  do  not  feel  justified  in  subjecting  their  patients  to  a  form 
of  treatment  of  which  they  have  not  personally  seen  a  practical  application 
we  would  suggest  that  they  continue  to  treat  their  cases  precisely  as  they 
have  up  to  the  present  time,  but  that  immediately  upon  being  called  to  see  a 
case  of  severe  acute  appendicitis  they  carefully  cocainize  the  pharynx  by 
spraying  with  a  two  per  cent,  solution,  then  wait  for  five  to  seven  minutes 
until  the  cocain  has  had  time  to  have  its  maximum  effect.  That  then  they 
introduce  a  stomach  tube  and  remove  any  substance  which  may  be  present 
in  the  stomach  by  irrigating  with  warm  normal  salt  solution.  That  then  no 
food  of  any  kind  whatsoever,  or  cathartics,  be  given  by  mouth  until  the 
patient  has  been  normal  for  four  days,  no  matter  whether  or  not  an 
immediate  operation  be  performed.  The  nutrition  may  in  the  meantime  be 


278  GENERAL     SURGERY     OF     THE     ABDOMEN 

carried  on  by  giving  a  nourishing  enema,  every  three  to  four  hours,  con- 
sisting of  one  of  the  various  concentrated  liquid  foods  in  the  market, 
dissolved  in  three  ounces  of  normal  salt  solution,  through  a  catheter  inserted 
into  the  rectum  a  distance  of  two  to  three  inches. 

We  would  suggest  that  this  plan  be  followed  in  all  cases  in  which  the 
patients  or  their  friends  absolutely  refuse  an  operation. 

This  plan  has  now  been  practised  by  a  large  number  of  physicians  and 
surgeons,  and  all  of  those  who  have  actually  carried  out  the  principles  set 
forth  in  the  above  conclusions  have  found  a  very  marked  reduction  in  their 
mortality.  We  have  received  a  large  number  of  letters  from  physicians 
testifying  to  this  fact,  and  many  others  have  personally  reported  equally 
satisfactory  results. 

Our  own  experience  and  observation  is  borne  out  by  many  others  to 
the  effect  that  the  administration  of  any  form  of  nourishment  or  cathartics, 
or  both,  by  mouth  has  caused  an  enormous  number  of  deaths  in  patients 
suffering  from  acute  appendicitis,  and  that  its  prohibition  will  save  a 
correspondingly  large  number  of  lives. 

We  have  been  informed  by  many  physicians  that  before  this  method  was 
introduced  in  their  practice  they  had  many  deaths  from  acute  appendicitis 
and  that  now  they  almost  never  lose  a  patient  from  this  cause.  When  we 
consider  the  effect  this  treatment  has  had  upon  the  enormous  number  of 
these  cases  that  have  come  under  our  observation  at  the  Augustana  hospital 
we  readily  comprehend  these  statements. 

ACUTE  GANGRENOUS  APPENDICITIS. 
Typical  Case. 

Patient,  twenty-seven  years  of  age,  a  bookkeeper  by  occupation,  came 
under  care  one  hour  ago.  He  was  then  in  his  residence,  a  distance  of  two 
miles  from  the  hospital,  where  he  was  seen  in  consultation  with  his  physician, 
who  had  made  the  proper  diagnosis  before  requesting  consultation.  The 
patient  gives  the  following  history : 

Family  history  good.  As  a  child  he  had  suffered  from  measles,  but  was 
otherwise  well.  About  one  year  ago  he  suffered  an  attack  of  pain  in  the 
right  inguinal  region,  accompanied  by  vomiting  and  fever,  and  was  confined 
to  bed  for  about  one  week.  Has  been  more  or  less  constipated  during  the 
past  year  and  has  had  more  or  less  weakness  and  pain  in  the  right  inguinal 
region.  This  was  always  worse  after  having  eaten  heavily.  One  week  ago 
he  had  a  severe  attack  of  pain,  accompanied  by  vomiting  and  a  slight  amount 
of  fever.  He  was  confined  to  bed  for  three  days.  For  the  following  four 
days  he  was  up  and  about,  and  was  fairly  well  this  morning  when  he  felt  a 
slight  pain  before  rising.  He  ate  breakfast  and  at  about  ten  o'clock  was 
seized  with  most  violent  distress  in  the  right  inguinal  region,  accompanied  by 
vomiting,  chills  and  fever.  Suffers  from  severe  shock,  is  still  having  severe 
pain  in  the  right  inguinal  region,  although  he  received  a  hypodermic  injec- 
tion of  one-half  grain  of  morphia  before  coming  to  the  hospital.  In  the 
region  of  McBurney's  point  there  is  great  tenderness  and  the  muscles  are 
extremely  rigid.  His  temperature  is  100  degrees  F.  and  pulse  102.  There  is 
no  tumor  palpable. 

Diagnosis. 

We  have  here  again  a  fairly  typical  condition.  A  history  of  a  previous 
acute  attack  of  pain  in  the  right  inguinal  region,  accompanied  by  vomiting 


GENERAL     SURGERY     OF     THE     ABDOMEN  279 

and  fever,  which  must  have  been  sufficiently  severe  to  leave  the  appendix 
somewhat  impaired.  It  was  not  severe  enough  to  warrant  a  diagnosis  ot 
gangrenous  or  perforative  appendicitis,  but  it  might  have  been  due  to  an 
obstruction  to  the  lumen  of  the  appendix,  resulting  from  the  presence  ot 
an  enterolith  or  an  ulcer  in  the  cecal  end  of  the  appendix.  The  slight  attack 
a  week  ago  might  have  been  a  repetition  of  the  same  condition. 

At  the  present  moment  the  patient  is  still  suffering,  but  not  nearly  so 
much  as  one  hour  ago  at  his  residence,  where  he  was  fairly  in  convulsions 
because  of  the  extreme  pain  in  the  region  of  McBurney's  point.  The  large 
dose  of  morphia  he  received  before  coming  to  the  hospital  serves  to  disguise 
the  condition  somewhat.  This,  however,  does  not  matter,  because  there  can 
be  no  doubt  concerning  the  diagnosis. 

The  extreme  violence  of  the  attack  which  occurred  about  ten  hours  ago 
and  which  has  not  subsided  since;  the  increase  in  his  temperature;  the 
acceleration  of  his  pulse  and  the  bad  appearance  of  the  patient;  the  great 
rigidity  of  his  abdominal  muscles;  the  obstruction  to  the  passage  of  gas,  all 
go  to  show  that  he  is  suffering  from  a  gangrenous  appendicitis,  or  an 
impending  perforation  due  to  pressure  from  an  enterolith  or  the  accumula- 
tion of  pus  in  an  obstructed  ulcerated  appendix. 

Treatment. 

Only  two  forms  of  treatment  can  be  considered  in  a  case  of  this 
character:  i.  Immediate  operation.  2.  Palliative  treatment  according  to 
the  method  employed  in  the  previous  case  by  means  of  exclusive  rectal 
alimentation  and  consequent  elimination  of  peristalsis. 

Judging  from  the  history  here  given  and  from  the  conditions  we  find 
upon  examination  it  is  reasonable  to  suppose  that  at  the  present  time,  only 
ten  hours  after  the  beginning  of  the  attack,  the  infectious  material  is  still 
confined  to  the  appendix. 

The  following  advantages  may  be  brought  forward  in  favor  of  an 
immediate  operation  in  cases  like  the  one  before  us : 

i.  The  patient  will  almost  invariably  get  well;  it  is  an  accident  if  he  does 
not  recover.  2.  He  will  be  able  to  return  to  work  in  one  month.  3.  He 
cannot  have  a  recurrence.  4.  He  cannot  have  the  complications  resulting 
from  progressive  or  metastatic  infection.  5.  There  will  be  no  adhesions 
with  their  digestive  disturbances.  6.  There  will  be  no  ventral  hernia  because 
drainage  will  not  be  required.  7.  He  will  not  become  an  invalid  because 
of  one  or  another  of  the  possible  complications. 

It  is  quite  different  one  or  two  or  three  days  later  when  the  infection 
has  extended  to  the  tissues  beyond  the  appendix,  because  at  that  time 
we  would  have  to  expect  trouble  for  the  following  reasons:  i.  The  patient 
is  not  certain  to  recover,  even  in  the  hands  of  the  most  skillful  surgeons. 
2.  His  recovery  from  the  operation  is  likely  to  be  slow.  3.  It  may  not  be 
safe  to  remove  the  appendix  after  opening  the  abdomen,  hence  a  recurrence 
may  still  occur.  4.  The  operation  may  cause  an  extension  of  the  infection. 
5.  Adhesions  are  likely  to  follow  the  operation  performed  at  this  time 
because  drainage  will  probably  be  required.  6.  For  the  same  reason  hernia 
frequently  occurs  after  operations  performed  at  this  period. 

What  can  we  expect  in  case  the  patient  is  not  operated  immediately,  but 
treated  by  the  preceding  method  described? 

In  cases  like  the  one  before  us,  in  which  we  have  been  compelled  to 
employ  this  method  because  the  patient  or  his  friends  absolutely  refused  an 


28O  GENERAL     SURGERY     OF     THE     ABDOMEN 

operation,  we  have  found  the  pain  subside  rapidly  after  employing-  gastric 
lavage  and  that  the  other  symptoms  decline  within  twenty-four  or  forty-eight 
hours,  or  at  the  latest  seventy-two  hours,  with  the  exception  of  the  tender- 
ness upon  pressure.  In  some  cases  a  circumscribed  abscess  formed,  which 
had  to  be  opened  externally  or  it  ruptured  into  the  cecum.  If  permitted  to 
remove  the  appendix  later  it  would  be  found  eliminated  from  the  general 
peritoneal  cavity  by  means  of  adhesions  to  the  omentum,  the  cecum  or  the 
iliacus  muscle.  If  it  was  not  removed  later  these  patients  usually  had  recur- 
rent attacks  of  appendicitis. 

We  would  consequently  say  in  considering-  patients  in  the  condition  of 
the  one  just  described  that  if  a  safe  surgeon  is  available  such  patients  should 
invariably  be  operated  on  at  once  for  the  reasons  given,  which  will  undoubt- 
edly become  more  apparent  as  we  proceed  with  the  operation.  It  is  for  this 
reason  that  the  family  physician  requested  consultation  with  a  surgeon  as 
soon  as  he  had  made  his  diagnosis,  and  for  the  same  reason  we  agreed  upon 
sending  this  patient  to  the  hospital  the  moment  we  had  concluded  the  con- 
sultation. We  have  lost  no  time,  for  while  the  patient  was  on  the  way  to  the 
hospital  all  preparations  for  the  operation  were  made  here  so  that  we  could 
proceed  at  once. 

Technique. 

The  patient  is  so  tender  that  it  will  not  be  possible  to  prepare  the  field 
of  operation  before  he  has  been  anesthetized.  We  will  consequently  proceed 
with  the  anesthesia  and  then  prepare  the  field  of  operation  in  the  usual 
manner,  being  extremely  careful,  however,  not  to  exercise  a  sufficient  amount 
of  force  to  complete  an  impending  perforation  of  the  appendix. 
Incision. 

It  seems  safe  in  this  instance  to  make  use  of  McBurney's  incision 
described  in  connection  with  the  previous  case,  because  this  will  leave  the 
abdominal  wall  least  impaired  after  the  wound  has  healed.  Had  the  patient 
experienced  several  very  severe  attacks  of  appendicitis,  it  might  be  reasonable 
to  suppose  that  much  space  would  be  required  for  the  removal  of  the 
appendix,  which  could  not  readily  be  obtained  through  this  incision.  Should 
we  find  conditions  more  complicated  after  opening  the  abdominal  wall  than  is 
to  be  expected  from  present  indications  we  shall  still  be  able  to  secure  an 
increase  in  the  size  of  the  wound. 

It  is  not  likely  that  we  will  find  an  abscess  outside  the  appendix  directly 
underneath  the  abdominal  wall,  as  this  is  usually  accompanied  by  a  condition 
of  edema  of  the  tissues  composing  the  abdominal  wall.  Nevertheless,  it  is 
wise  to  be  exceedingly  cautious  in  making  the  incision  through  the  transver- 
salis  fascia  and  peritoneum,  in  order  to  avoid  injuring  the  underlying  intes- 
tines which  may  be  slightly  adherent  either  from  the  attack  the  patient  experi- 
enced a  year  ago  or  from  the  present  attack,  because  frequently  these  adhe- 
sions precede  the  perforation.  This  process  might  have  taken  place  during  the 
slight  attack  the  patient  had  one  week  ago. 

Upon  opening  the  peritoneum  we  see  a  tense,  sausage-like  object  pro- 
jecting forward  between  the  ileuni  and  the  lower  end  of  the  cecum.  It  is 
surrounded  entirely  by  a  fold  of  omentum,  being  adherent  apparently  only 
behind  to  the  cecum  and  with  this  to  the  iliacus  muscle.  There  are  no  strong 
adhesions  to  the  omentum,  but  this  structure  seems  to  be  loosely  agglutinated 
to  the  appendix  by  means  of  a  delicate  layer  of  leucocytic  exudate.  In  strip- 


B 


PLATE  XXIII. 

CONSTRICTED  APPENDIX. 

Represents  the  vermiform  appendix  with  a  constriction  near  its  czecal  end.  The 
mesenteriolum  extends  a  little  beyond  the  end  of  the  appendix.  The  latter  is  markedly 
oedematous.  Fig.  B  represents  it  laid  open,  showing  faecal  concretions  in  its  lumen, 
and  also  showing  the  constriction  near  its  csecal  end. 


GENERAL    SURGERY    OF    THE    ABDOMEN  283 

ping  away  the  omentum  there  is  no  bleeding  and  neither  the  omentum  nor  the 
appendix  is  abraded. 

Before  attempting  to  remove  the  appendix  we  lift  up  the  abdominal 
wall  carefully  and  tampon  the  space  around  it  with  soft  pads  of  aseptic  gauze 
saturated  with  warm  normal  salt  solution,  in  order  to  prevent  contamination 
of  the  remaining  portion  of  the  abdominal  cavity  in  case  of  rupture  of  the 
distended  appendix.  This  leaves  the  other  portions  of  the  abdominal  cavity 
virtually  out  of  the  field  of  operation,  which  is  especially  important  in  a 
case  like  the  one  before  us,  because  we  know  that  the  appendix  contains 
septic  material  and  we  must  guard  against  its  introduction  into  the  abdominal 
cavity.  Here  we  will  carefully  dissect  up  the  appendix  from  its  distal  end, 
going  very  cautiously  and  grasping  every  bleeding  point  with  hemostatic 
forceps  as  we  proceed,  and  applying  a  fine  catgut  ligature  each  time  in  order 
to  prevent  mischief  by  pulling  upon  these  forceps. 

It  is  often  much  better  to  apply  two  pair  of  forceps  to  the  cecal  end  of 
the  appendix  and  then  cut  between  these,  thus  severing  the  appendix  from 
the  cecum.  Then  hemostatic  forceps  are  applied  successively  to  the  mesenteri- 
olum  and  this  severed  so  far  as  caught  in  the  grasp  of  the  forceps  with  each 
successive  forceps  that  are  applied.  In  cases  in  which  the  appendix  is  adherent 
to  the  posterior  surface  of  the  cecum  this  method  is  especially  useful  in  re- 
during  the  necessary  manipulations. 

The  appendix  is  extremely  tense,  and  half  an  inch  from  its  distal  end 
there  is  a  greyish,  dark,  discolored  point,  a  circumscribed  gangrene.  The 
mesentery  extends  to  the  end  of  the  appendix,  but  is  not  free.  Evidently  the 
inflammatory  disturbance  of  one  year  ago  resulted  in  the  adhesion  which 
attached  this  mesentery  to  the  lower  end  of  the  cecum  and  to  the  iliacus 
muscle.  The  mesentery  is  so  short  that  it  is  not  possible  to  grasp  it  with 
hemostatic  forceps  or  to  ligate  it  before  cutting,  hence  it  will  be  necessary  to 
dissect  loose  the  appendix  and  to  grasp  the  mesenteric  artery  when  it  is 
divided.  This  is  ligated  directly  and  now  we  have  the  appendix  free  in  the 
wound  projecting  from  the  lower  end  of  the  cecum,  like  a  sausage,  three 
and  one-half  inches  in  length  and  three-fourths  of  an  inch  at  its  greatest  di- 
ameter. It  is  slightly  curved  upon  itself  and  its  walls  are  edematous.  After 
surrounding  the  appendix  with  warm,  moist  gauze  pads,  in  order  to  protect 
the  wound  in  case  of  rupture,  we  apply  two  pairs  of  narrow,  long-jawed  for- 
ceps upon  the  cecal  end  of  the  appendix  and  cut  between.  From  this  point  on 
the  operation  proceeds  precisely  as  described  in  connection  with  the  previous 
case,  with  the  exception  that  a  little  greater  care  is  exercised  in  applying  the 
sutures  in  the  cecum,  because  of  the  increased  vascularity  due  to  the  acute 
congestion.  Unless  these  stitches  are  applied  carefully  there  is  sometimes 
troublesome  oozing  from  blood  vessels,  which  are  at  other  times  too  small  to 
be  noticed. 

An  examination  of  the  specimen  removed  shows  that  the  appendix  is 
completely  occluded  at  its  cecal  end  on  account  of  cicatricial  contraction  due 
to  destruction  of  its  mucous  lining,  which  probably  occurred  during  the  at- 
tack a  year  ago.  The  appendix  contains  pus  and  mucus  and  a  slight  amount 
of  fecal  material  in  flakes.  This  seems  to  indicate  that  the  cecal  end  of 
the  lumen  was  not  completely  occluded  until  the  beginning  of  the  present 
attack.  The  mucous  membrane  lining  the  appendix  is  severely  congested 
and  dark  and  a  short  distance  from  the  distal  end  there  is  an  area  of  about 
half  an  inch  in  diameter  which  is  gangrenous.  The  edematous  condition  of 


284  GENERAL    SURGERY    OF    THE    ABDOMEN 

the  tissues  in  the  walls  of  the  appendix  is  very  apparent  on  the  surface  of  the 
section  we  have  made  longitudinally  through  this  organ. 

It  is  quite  plain  that  the  removal  of  this  organ  must  be  the  proper  treat- 
ment in  cases  like  the  one  before  us,  provided  this  can  be  accomplished 
safely,  for  the  reasons  which  have  been  given,  but  it  is  equally  plain  that  in 
such  cases  it  would  be  an  easy  matter  to  infect  the  general  peritoneal 
cavity,  which  would  of  course  be  a  very  serious  accident. 

This  case  has  developed  today  with  great  severity,  and  still  the  condi- 
tions we  found  were  favorable  for  the  protection  of  the  general  peritoneal 
cavity  against  infection,  had  peristalsis  been  eliminated  by  the  method  de- 
scribed previously.  The  appendix  was  surrounded  by  the  omentum  which 
would  have  disposed  of  a  great  amount  of  infection  and  would  at  least  have 
protected  the  general  peritoneal  cavity  against  infection.  It  is  likely,  then, 
that  with  this  treatment  even  so  violent  a  case  as  this  would  be  in  the  worst 
instance,  has  resulted  in  a  circumscribed  abscess  in  the  right  inguinal  region. 
It  is  for  this  reason  that  we  believe  laparotomy  should  be  performed  for  the 
relief  of  acute  appendicitis  only  when  a  safe  surgeon  is  at  hand  and  when  the 
other  conditions  are  such  as  to  make  a  recovery  fairly  certain. 

The  conditions  here  and  in  many  other  similar  instances  which  we  have 
operated  during  the  first  thirty-six  hours  of  an  acute  attack,  show  how  ex- 
tremely dangerous  it  is  to  encourage  peristaltic  motion  of  the  small  intestines 
by  the  giving  of  food  and  cathartics  by  mouth.  Such  action  would  probably 
have  been  followed  by  a  perforation  at  the  point  at  which  the  wall  of  the 
appendix  was  gangrenous  and  this  would  have  been  followed  by  the  rapid  dis- 
tribution of  the  infectious  material  to  distant  parts  of  the  peritoneal  cavity. 
Had  the  gangrenous  portion  been  toward  the  cecuin  a  perforation  would 
probably  have  taken  place  into  the  lumen  of  the  intestine,  which  \vould  have 
been  favorable  for  the  recovery  of  the  patient. 

Had  we  found  it  impossible  to  remove  the  appendix  safely  through  the 
incision  which  was  made  in  the  present  case  the  required  space  could  have 
been  obtained  by  cutting  the  outer  edge  of  the  fascia  covering  the  rectus  ab- 
dominis  muscle,  which  would  have  made  it  possible  to  slide  the  inner  por- 
tion of  the  edges  of  the  internal  oblique  muscle  apart  a  considerable  dis- 
tance. If  this  still  failed  to  give  a  sufficient  amount  of  space  the  internal 
oblique  abdominal  muscle  could  have  been  cut  at  right  angles  to  the  direction 
of  its  fibers,  as  shown  in  Plate  XXVII. 

Of  course  this  incision  may  be  lengthened  indefinitely,  although  al- 
ways done  at  the  risk  of  weakening  the  abdominal  wall  to  a  great  extent,  be- 
cause a  muscle  once  cut  at  right  angles  to  its  fibers  can  never  be  restored 
to  an  absolutely  normal  condition,  hut  circumstances  may  occur  which  make 
it  necessary  to  do  this  in  order  to  secure  a  sufficient  amount  of  space  to 
make  the  removal  of  an  extensively  adherent  appendix  possible 

If  such  a  condition  is  anticipated  it  is.  of  course,  much  wiser  to  make 
the  incision  through  the  edge  of  the  right  rectus  abdominis  muscle,  as  this 
commands  the  field  of  operation  equally  well  and  the  incision  may  be  length- 
ened according  to  the  necessities  of  the  case,  but  if  this  has  not  been  antici- 
pated it  sometimes,  though  rarely,  becomes  necessary  to  increase  the  space  as 
indicated  in  Plate  XXVI 1.  Then  the  incision  may  be  carried  through  the 
lower  or  the  upper,  or  through  both  edges  of  the  muscle,  according  to  the 
direction  in  which  increased  space  is  desired  for  the  safe  removal  of  the 
appendix  in  any  given  case.  If  this  has  been  done  it  is  important  to  secure  a 


GENERAL    SURGERY    OF    THE    ABDOMEN  285 

closure  of  the  abdominal  wound,  which  will  prevent  the  formation  of  a 
ventral  hernia. 

In  order  to  accomplish  such  a  result  we  would  suggest  the  following 
steps :  Deep  silk-w-ormgut  sutures  are  first  inserted  through  all  layers  down 
to,  but  not  through,  the  transversalis  fascia,  as  in  Plate  XXVIII.  These 
stitches  are  left  untied  until  the  buried  sutures  have  been  applied,  then  they 
are  tied  over  all,  acting  simply  as  stay  sutures.  The  peritoneum  and  the 
transversalis  fascia  are  next  sutured  with  continuous  catgut,  great  care  being 
taken  to  secure  as  perfect  coaptation  as  possible,  because  the  transversalis 
fascia  gives  valuable  support  to  the  abdominal  wall  at  this  point  and  if 
properly  united  will  aid  greatly  in  preventing  the  occurrence  of  a  ventral 
hernia.  The  transverse  incision  in  the  internal  oblique  muscle  is  next  re- 
paired, making  it  as  nearly  normal  as  possible,  as  shown  in  Plate  XXIX.  For 
this  purpose  we  have  used  interrupted  stitches  of  fine,  chromicized  catgut 
used  double.  Ordinary  catgut  might  be  absorbed  before  the  muscle  ends 
had  been  thoroughly  united  and  the  retraction  of  the  latter,  due  to  muscular 
contraction,  would  leave  a  point  of  weakness  in  the  abdominal  wall. 

It  is  likely  that  in  aseptic  cases  these  muscles  will  unite  very  quickly.  We 
have  been  compelled  to  enlarge  the  abdominal  wound  in  this  manner  in  only 
a  few  cases  and  in  these  the  result  has  been  perfectly  satisfactory;  but  we 
have  a  great  aversion  toward  any  operation  which  contemplates  the  cutting 
of  abdominal  muscles  at  right  angles  and  should  not  advise  such  an  act  ex- 
cept where  the  McBurney  incision  seemed  to  be  the  best  at  the  time  the  op- 
eration was  begun,  but  proved  not  sufficiently  large  to  dispose  of  the  condi- 
tions found  after  the  abdomen  was  opened.  The  further  steps  in  the  pro- 
cedure are  the  same  as  described  in  connection  with  the  previous  operation. 

ACUTE  APPENDICITIS  WITH   SECONDARY   INFECTION   OF   PELVIC 

ORGANS  IN  THE  FEMALE. 
Typical  Case. 

The, patient  is  a  school  girl,  sixteen  years  of  age;  has  always  enjoyed 
good  health,  having  grown  up  in  the  country.  She  menstruated  at  thirteen 
years  of  age.  and  was  without  pain  until  one  year  ago.  when  she  suffered 
from  a  typical  attack  of  appendicitis.  Since  then  she  has  suffered  severely 
during  each  menstrual  period.  She  has  had  four  typical  attacks  of  appendi- 
citis during  the  past  year;  the  last  one  began  one  month  ago  and  she  is  just 
now  recovering.  Her  present  condition  is  that  of  a  very  well  nourished  girl, 
evidently  unusually  strong  and  vigorous  when  in  good  health  ;  tongue  is 
clear;  appetite  good  previous  to  recent  attack,  now  absent;  heart,  lungs  and 
kidneys  normal.  A  slight  swelling  is  perceptible  over  the  region  of  the 
appendix,  also  slight  dullness  on  percussion  ;  vaginal  examination  cannot  be 
made  as  patient  is  a  virgin.  She  has  been  nauseated,  but  has  abstained  from 
food  almost  completely  during  this  attack. 

Class  Characteristics. 

This  patient  belongs  t<>  a  class  which  is  not  at  all  uncommon.  The 
characteristic  feature  lies  in  the  fact  that  although  the  first  attack  was  typical 
of  acute  appendicitis  and  the  recurrent  attacks  were  similar  in  character, 
there  is  in  addition  a  dysmenorrheic  pain,  which  is  more  frequently  right- 
sided.  The  pain  may  be  so  high  in  the  abdomen  as  to  indicate  a  diagnosis  of 
recurrent  appendicitis  with  each  menstrual  period,  but  the  fact  that  it  oc- 


286  GENERAL    SURGERY    OF    THE    ABDOMEN 

curs  regularly  at  this  time  usually  results  in  a  diagnosis  of  dysmenorrhea 
and  is  more  commonly  attributed  to  disease  of  the  ovary  and  tube  than  to 
the  appendix.  The  fact  that  menstruation  was  painless  and  normal  previous 
to  the  primary  attack  of  appendicitis,  and  that  the  patient  is  a  virgin,  would 
indicate  that  the  disease  must  have  begun  in  the  appendix.  It  may  still  be 
confined  to  the  appendix  and  the  exacerbation  may  be  due  to  the  congestion 
incident  to  the  changes  present  during  the  menstrual  period.  The  close  con- 
nection between  the  right  ovary  and  tube  and  the  appendix,  due  to  the  pres- 
ence of  the  appendico-ovarian  ligament  of  Clado,  would  readily  explain  the 
effect  of  this  congestion  upon  a  chronic  appendicitis.  We  have  repeatedly 
seen  cases  where  the  cecal  end  of  the  appendix  was  almost  completely  ob- 
structed and  the  distal  end  thereof  contained  fecal  concretions  or  pus 
or  mucus  in  which  the  irritation  or  congestion  due  to  the  menstrual 
period  seemed  to  suffice  to  cause  a  complete  obstruction  temporarily  each 
month,  and  thus  produce  a  mild  attack  of  appendicitis  without  resulting  in  a 
disease  of  the  ovary  and  tube. 

In  other  cases  in  which  the  primary  attack  of  appendicitis  is  severe 
enough  to  result  in  an  infection  extending  beyond  the  vermiform  appendix 
the  conditions  found  are  quite  different.  There  may  have  been  a  perforation 
of  the  appendix  and  some  of  the  septic  material  escaping  from  the  immediate 
vicinity  of  the  appendix  into  the  pelvis  may  there  have  been  taken  up  by 
the  fimbriated  extremity  of  the  Fallopian  tube,  through  which  it  may  have 
been  carried  in  the  direction  of  the  uterus  by  means  of  the  ciliated  epithelium 
lining  this  tube.  The  infection  may  have  been  sufficiently  violent  in  charac- 
ter to  destroy  a  portion  of  the  lining  of  this  tube,  and  thus  have  resulted  in 
an  obstruction,  or  an  adhesion  may  have  been  formed  between  the  fimbriated 
extremity  of  the  Fallopian  tube  and  the  ovary,  or  between  any  of  the  other 
pelvic  organs,  or  directly  between  the  appendix  and  the  Fallopian  tube ;  all 
or  any  of  these  organs  may  have  become  adherent  to  the  omentum. 

Indications  for  Operation. 

The  increasing  severity  of  the  attack,  and  the  fact  that  although  the 
patient  has  recovered  from  the  last  seizure,  she  still  has  a  perceptible  mass  in 
the  region  of  the  appendix,  would  indicate  a  sufficient  amount  of  pathological 
change  to  warrant  the  removal  of  the  diseased  appendix.  It  seems,  how- 
ever, that  the  severe  dysmenorrhea  which  has  recurred  regularly  with  each 
menstrual  period  since  the  first  attack  of  appendicitis  should  be  seriously 
considered. 

This  condition  is  undoubtedly  clue  to  the  secondary  involvement  of  the 
right  ovary  and  tube.  If  the  patient  is  not  relieved  of  the  cause  of  this  severe 
suffering,  which  occurs  at  such  short  intervals,  she  will  undoubtedly  soon 
become  a  neurotic  wreck,  because  she  will  soon  be  unable  to  recover  fully 
from  one  attack  before  the  beginning  of  the  next  one. 

It  is  also  likely  that  many  cases  of  sterility  result  from  the  infection  of 
the  Fallopian  tubes  having  its  origin  in  an  appendicitis ;  hence  the  sooner  the 
latter  condition  is  eliminated  the  greater  the  likelihood  of  averting  such  a 
result.  This  seems  of  sufficient  importance  to  influence  our  plan  of  treat- 
ment of  acute  or  recurrent  appendicitis  in  young  girls.  The  possibility  of 
involvement  of  the  pelvic  organs,  with  their  special  complications,  should 
demand  the  removal  of  the  diseased  appendix  more  imperatively  than  in  male 
children. 

We  have  also  observed  many  times  that  these  children  were  badly  de- 


PLATE  XXIV. 

ADHERENT  APPENDIX. 

Represents  the  crecum  together  with  the  ileum  and  the  mesentery  of  the  latter. 
The  appendix  is  bent  upon  itself  in  the  form  of  an  interrogation  point.  It  is  strongly 
attached  by  adhesions  to  the  lower  end  of  the  crecum.  The  lymph  glands  in  its 
mesentery  are  greatly  enlarged. 


> 

H 


<J 


PLATE  XXVI. 
ADHERENT  APPENDIX. 

Represents  the  vermiform  appendix  bent  upon  itself,  making  several  sharp  angles, 
held  in  position  upon  the  lower  end  of  the  caecum  by  strong  adhesions,  one  of  the 
latter  extending  over  upon  the  ileum.  The  end  of  the  appendix  is  free.  The  mesen- 
teriolum  is  narrow,  but  it  extends  to  the  end  of  the  appendix. 


PLATE  XXVII. 

AKDOMINAL   INCISION. 

Represents  McBurney's  incision  for  the  removal  of  the  vermiform  appendix,  in 
which  the  internal  oblique  abdominal  muscle  has  been  cut  transversely  in  order  to 
increase  the  opening  sufficiently  to  loosen  an  appendix  adherent  in  the  pelvis.  This 
incision  across  the  muscle  is  not  desirable. 


PLATE  XXVIII. 
ABDOMINAL  INCISION. 

Represents  the  method  of  closing  the  incision  shown  in  Plate  XXVII,  the  deep 
silkworm  gut  sutures  grasping  all  layers  down  to  the  transversalis  fascia,  but  being' 
left  untied  until  all  of  the  layers  have  been  united  separately  by  means  of  cat-gut 
sutures 


PLATE  XXIX. 

ABDOMINAL  IXCISTOX. 

Represents  the  method  of  applying  interrupted  sutures  in  order  to  restore  the 
internal  oblique  abdominal  muscle,  in  the  same  case  the  external  oblique  being  held 
out  of  the  wav  bv  means  of  retractors. 


fk  /"" /*' 


PLATE  XXX. 
CutsrKK  OF  McHrRNKY  INCISION. 

By  suturing  the  fascia  of  the  external  oblique  muscle  separately,  as  indicated  in 
this  plate,  there  is  one  strong  layer  which  is  perfectly  restored,  which  will  compensate 
for  a  portion  of  the  defect  in  the  internal  oblique,  as  shown  in  Plate  XXIX. 

The  deep  silkworm  gut  sutures  are  drawn  double.  It  is  scarcely  necessary  to  take 
this  additional  precaution,  but  the  support  from  this  source  is  undoubtedly  of  value 
until  the  injury  to  the  internal  oblique  muscle  has  had  time  to  become  repaired.  The 
deep  sutures  are  tied  after  all  of  the  layers  have  been  separately  united  with  cat-gut 
sutures. 


GENERAL    SURGERY    OF    THE    ABDOMEN  3<>I 

veloped  physically  and  mentally  when  they  came  under  care  for  the  removal 
of  an  appendix  which  had  been  diseased  to  a  slight  extent  for  several  years. 
The  history  would  show  that  there  had  been  little  or  no  progress  in  the 
child's  physical  and  mental  development  for  several  months  or  years.  Many 
of  these  cases  develop  rapidly  after  removing  the  diseased  appendix,  often 
times  gaining  more  in  six  months  than  they  had  in  the  previous  two  or 
three  years. 

In  many  ovarian  cysts  we  have  found  the  remnants  of  an  appendix, 
once  perforated  or  partly  destroyed  by  gangrenous  appendicitis.  It  is  possi- 
ble that  the  cicatricial  tissue  which  formed  upon  the  surface  of  the  ovary  be- 
cause of  the  peritonitis  in  this  vicinity  secondary  to  the  appendicitis  may  be 
responsible  for  the  formation  of  some  of  these  cysts. 

The  same  is  true  of  extra-uterine  pregnancy,  although  in  this  condition 
there  is  more  commonly  a  history  of  an  infection  of  the  Fallopian  tubes 
through  the  uterine  cavity. 
Technique. 

In  this  case  it  seems  wise  to  make  the  incision  through  the  outer  edge  of 
the  right  rectus  abdominis  muscle,  as  indicated  in  Plates  XIII  and  XIV, 
because  we  may  require  a  considerable  amount  of  space  through  which  to 
safely  remove  an  extensively  adherent  appendix.  Moreover,  it  may  be  desir- 
able to  remove  the  right  ovary  and  tube  if  they  are  sufficiently  involved  to 
make  their  complete  recovery  to  normal  unlikely.  This  incision  can  be  made 
as  short  as  desirable  until  the  conditions  have  been  determined  and  then  it 
may  be  lengthened  upward  or  downward  as  indicated  by  the  circumstances. 

The  mass  which  we  were  able  to  palpate  through  the  abdominal  wall 
consists  of  the  omentum  surrounding  the  appendix  and  the  lower  end  of  the 
cecum,  and  adherent  to  the  lower  end  of  this  mass  we  find  the  right  Fallopian 
tube,  which  is  closed  at  its  fimbriated  extremity,  and  the  ovary  which  is 
severely  congested  and  twice  the  size  of  the  left  ovary,  which  is  free  and 
normal. 

In  order  to  prevent  an  infection  of  the  surrounding  portions  of  the  peri- 
toneum we  tampon  these  away  with  a  large  piece  of  moist  aseptic  gauze.  It 
is  now  one  month  since  the  beginning  of  the  last  attack,  consequently  the 
pus  which  may  be  present  is  not  likely  to  contain  any  very  virulent  micro- 
organisms. It  is,  nevertheless,  wise  to  take  the  same  precautions  against  an 
infection.  We  will  now  proceed  to  follow  the  longitudinal  band  on  the  an- 
terior surface  of  the  cecum  as  the  most  reliable  guide  to  the  location  of  the 
appendix,  being  careful  to  do  as  little  mischief  as  possible  in  loosening  the 
adhesions. 

As  we  loosen  the  omentum  a  small  quantity  of  pus  is  beginning  to 
escape,  which  we  sponge  away  with  great  care  before  there  is  any  chance 
of  causing  an  infection.  The  abscess  contains  about  half  an  ounce  of  pus 
and  a  fecal  concretion  the  size  and  shape  of  an  olive  stone,  and  the  per- 
forated appendix  which  is  constricted  at  the  cecal  end  and  somewhat  club- 
shaped  at  its  distal  end.  We  ligate  the  portion  of  the  omentum  which  helps 
to  form  the  abscess  wall  and  treat  the  appendix  as  in  the  previous  cases,  after 
carefully  separating  it  from  its  adhesions  to  the  lower  end  of  the  cecum,  to 
the  anterior  surface  of  the  iliacus  muscle  and  to  the  right  ovary  and  Fallopian 
tube,  which  have  been  involved  secondarily.  When  the  perforation  of  the 
appendix  occurred  some  of  the  pus  evidently  escaped  into  the  pelvis  and 
was  taken  up  by  the  fimbriated  extremity  of  the  Fallopian  tube,  becoming 


3O2  GENERAL    SURGERY    OF    THE   ABDOMEN 

infected.    The  fimbrise  became  adherent  to  each  other  and  to  the  ovary,  and 
to  the  lower  end  of  the  adherent  mass. 

Occasionally  it  is  better  to  sever  the  appendix  at  its  cecal  end  and  to  in- 
vert the  stump  and  close  the  defect  in  the  cecum  as  described  in  the  previous 
operations,  and  then  to  enucleate  the  appendix,  because  in  this  manner  the 
cecum  may  be  pushed  out  of  the  way  and  more  room  gained,  which  will 
serve  to  facilitate  the  enucleation.  The  same  method  may  sometimes  be  em- 
ployed for  the  removal  of  an  infected  Fallopian  tube  and  ovary,  the  enuclea- 
tion being  started  from  the  uterine  side,  the  tube  being  first  severed  at  the 
uterine  end  and  then  enucleated  from  within  outward. 

In  enucleating  the  inflamed  adherent  appendix  it  is  important  to  bear 
in  mind  the  fact  that  the  appendicular  artery,  which  is  found  in  the  remnant 
of  the  mesenteriolum  of  the  appendix,  is  a  vessel  of  considerable  size,  and 
that  a  fatal  hemorrhage  may  occur  if  this  vessel  is  not  thoroughly  controlled. 
The  tissues  are  often  so  fragile  that  it  is  difficult  to  grasp  this  artery  with 
hemostatic  forceps  without  crushing  it  off  and  thus  increasing  the  hem- 
orrhage. If  this  fact  is  borne  in  mind,  however,  it  is  possible  to  grasp  this 
vessel  and  ligate  it  safely. 

Ordinarily,  all  of  these  steps  may  be  carried  out  safely  if  the  wound  is 
made  sufficiently  long  to  permit  the  operation  to  be  performed  in  plain  sight ; 
if  the  other  portions  of  the  peritoneal  cavity  are  carefully  tamponed  away ; 
if  the  appendix  is  located  without  unnecessary  manipulations  by  using  the 
longitudinal  band  on  the  anterior  surface  of  the  cecum  as  a  guide  and  if  the 
entire  operation  is  performed  without  unnecessary  manipulation. 

With  increasing  experience  each  surgeon  learns  to  recognize  his  own 
ability  in  these  manipulations  and  can  determine  with  a  fair  degree  of  cer- 
tainty how  much  he  can  safely  undertake  to  do  in  any  given  case. 

It  would,  of  course,  be  much  better  simply  to  drain  the  abscess  and 
later  to  remove  the  appendix,  than  to  do  the  thorough  operation,  if  this 
seemed  safer  in  any  given  case,  because  a  second  operation  for  the  removal 
of  the  appendix  could  be  very  safely  performed  at  a  future  time.  This,  how- 
ever, must  be  left  to  the  judgment  of  the  surgeon  who  happens  to  perform 
the  operation,  as  the  point  to  be  determined  is  not  what  is  the  best  treatment 
for  such  cases  in  general,  but  what  is  the  best  treatment  for  the  case  under 
consideration  with  the  skill  and  experience  at  hand.  The  general  principle, 
however,  is  applicable  to  these,  as  to  all  cases  in  surgery,  that,  other  things 
being  equal,  the  more  thorough  the  operation  performed,  the  better. 
Drainage. 

Although  we  have  removed  this  appendix,  the  infected  omentum,  the 
ovary  and  the  tube  without  contaminating  any  other  portion  of  the  perito- 
neum, and  although  we  have  apparently  removed  all  infectious  material,  the 
question  whether  or  not  it  is  wise  to  drain  must  still  be  considered.  The  fact 
that  an  abscess  has  existed  makes  drainage  permissible.  In  our  own  work, 
we  drain  much  less  frequently  now  than  in  former  years,  yet  when  there  is 
the  slightest  doubt  in  any  given  case  we  always  drain. 

Should  we  drain  in  this  case  through  any  portion  of  the  abdominal 
wound  which  extends  through  the  edge  of  the  right  rectus  abdominis  muscle 
a  hernia  would  very  likely  result,  because  the  connective  tissue  formed  in  the 
closure  of  the  drainage  opening  would  be  very  likely  to  give  way.  We  con- 
sequently make  a  little  incision  one  inch  in  length  parallel  to  the  fibers  of  the 
external  oblique  muscle  two  inches  to  the  right  of  McBurney's  point.  This 


PLATE  XXXT. 

MEANS  FOR  PREVENTING  SUTURE  MARKS. 

If  it  is  desired  to  avoid  the  occurrence  of  marks  due  to  the  cutting  of  deep 
sutures  this  can  be  accomplished  by  placing  a  roll  of  gauze  directly  upon  the  wound 
and  tying  the  sutures  over  this,  as  indicated  in  this  plate.  The  same  precaution 
against  drawing  the  sutures  too  tightly  must  of  course  be  observed  if  this  method  is 
employed,  as  in  tying  the  sutures  in  the  usual  manner. 

The  method  produces  more  uniformly  perfect  results,  so  far  as  the  absence  of 
an  offensive  scar  is  concerned,  than  the  subcuticular  suture. 


GENERAL    SURGERY    OF    THE    ABDOMEN  305 

incision  is  carried  through  the  fibers  of  the  external  oblique  muscle  down  to 
the  internal  oblique,  the  fibers  of  which  extend  at  right  angles  to  the  former. 
These  are  also  separated  and  then  a  small  opening  is  made  in  the  transversalis 
fascia  and  peritoneum.  Through  this  opening  we  carry  a  glass  drainage 
tube,  covered  with  one  or  more  layers  of  iodoform  gauze,  to  a  point  just  be- 
low the  cecum,  from  which  the  abscess  was  removed.  What  is  left  of  the 
omentum.  is  then  carried  over  this  surface  and  then  the  tampons  are  removed 
and  the  abdominal  wall  is  closed  in  the  usual  manner. 

After  Treatment. 

The  drainage  tube  is  removed  any  time  between  the  second  and  the 
fifth  day,  and  the  gauze  one  or  two  days  later,  when  the  drainage  wound  is 
permitted  to  heal.  Having  been  made  without  cutting  any  muscle  fibers,  this 
wound  will  never  cause  a  hernia,  because  the  edges  of  the  split  fibers  will  be 
drawn  together  as  a  result  of  muscular  contraction,  and  thus  the  small  open- 
ing will  be  efficiently  and  permanently  closed. 

For  the  first  three  days  the  patient  will  be  sustained  entirely  by  means 
of  rectal  feeding,  nutrient  enemata  being  given  every  four  hours,  as  described 
before.  If  the  patient  is  normal  at  the  end  of  this  time  a  moderate  amount 
of  liquid  nourishment  will  be  given  by  mouth  at  regular  intervals,  but  if  not 
normal  at  the  end  of  this  period  the  exclusive  rectal  alimentation  will  be  con- 
tinued. In  case  of  pain  morphia  can  be  safely  given,  preferably  by  hypo- 
dermic injections  so  long  as  no  food  is  given  by  mouth. 

In  a  few  cases  we  have  seen  both  ovaries  and  tubes,  as  well  as  the  uterus 
and  bladder,  involved  secondarily  in  acute  perforative  appendicitis.  The 
treatment  must,  of  course,  contemplate  the  relief  of  all  of  these  complications. 

Where  it  is  apparent,  before  the  abdomen  has  been  opened,  that  both 
ovaries  and  tubes  are  secondarily  involved,  it  is  usually  wise  to  choose  the 
median  incision,  because  from  this  the  affected  parts  can  all  be  reached,  ex- 
cept when  the  appendix  is  adherent  to  the  posterior  surface  of  the  cecum. 
However,  we  have  never  encountered  one  of  these  cases  with  a  secondary 
involvement  of  both  ovaries  and  tubes  in  which  the  diseased_  condition  of 
these  organs  could  not  be  recognized  by  a  vaginal  examination.  In  that 
case  the  median  incision  would,  of  course,  be  chosen. 

In  order  to  emphasize  its  importance  once  more,  it  is  suggested  that  in 
all  intra-abdominal  operations  performed  for  the  relief  of  dysmenorrhea, 
especially  if  this  is  more  strongly  marked  on  the  right  side,  it  is  wise  to  ex- 
amine the  appendix,  because  very  frequently  a  diseased  appendix  is  the  sole 
cause  of  dysmenorrhea. 

In  one  instance  in  which  there  was  a  free  discharge  of  pus,  filled  with 
colon  bacilli  from  the  vagina,  we  found  that  the  fimbriated  extremity  of  the 
right  Fallopian  tube  had  grasped  the  gangrenous  end  of  the  appendix  and 
that  this  end  had  never  healed  so  that  a  continuous  tube  extended  from 
the  cavity  of  the  cecum  to  the  cavity  of  the  uterus. 

APPENDICITIS  IN  CHILDREN. 

There  are  certain  features  in  connection  with  appendicitis  in  young 
children  which  require  especial  attention,  for  if  looked  upon  from  the  same 
standpoint  as  in  adults  our  results  will  not  attain  the  highest  degree  of  satis- 
faction. 


306  GENERAL    SURGERY    OF    THE   ABDOMEN 

History. 

Frequently  a  child  that  has  been  in  most  excellent  health,  whose  gen- 
eral appearance  indicates  no  disturbance,  whose  nutrition  is  good,  and  who 
is  in  no  way  suffering,  suddenly  develops  a  most  violent  attack  of  acute  ap- 
pendicitis. This  can  be  explained  in  the  following  manner :  The  appendix 
in  these  children  is  usually  large,  but  the  cecal  end  is  much  the  narrowest 
portion  of  the  lumen.  This  favors  the  formation  of  an  enterolith,  which 
eventually  either  obstructs  the  cecal  end  of  the  lumen  and  brings  about  an 
acute  appendicitis  or  it  causes  an  ulcer,  resulting  from  pressure  necrosis,  with 
the  same  ultimate  result. 

In  many  the  mesentery  of  the  appendix  is  very  short,  which  still  further 
facilitates  necrosis  of  the  portion  projecting  beyond  the  end  of  the  mesentery, 
because  in  case  of  a  thrombosis  of  one  of  the  vessels  in  this  portion  there  can 
be  no  compensatory  circulation,  while  this  can  readily  be  established  when 
the  mesentery  extends  to  the  end  of  the  appendix. 

Diagnostic  Error. 

One  peculiarity  in  appendicitis  in  children  is  the  fact  that  the  attack  is 
almost  always  looked  upon  by  the  parents  and  friends,  and  frequently  by  the 
physician,  as  a  case  of  violent,  acute  gastritis  or  enteritis,  resulting  from  some 
indiscretion  in  eating.  (In  most  cases  the  little  patient  has  indeed  eaten  an 
unreasonable  amount  of  some  especially  indigestible  substance  just  before 
the  attack  began.)  This  is  so  common  that  one  rarely  sees  these  young  ap- 
pendicitis patients  in  whom  the  correct  diagnosis  was  made  from  the  begin- 
ning of  the  attack. 

The  omentum  in  young  children  is  very  small  and  not  very  substantial, 
hence  it  cannot  be  of  as  much  use  in  separating  the  diseased  appendix  from 
the  general  peritoneal  cavity  as  in  the  adult,  and  consequently  it  is  necessary, 
in  cases  which  come  too  late  for  an  early  operation,  to  watch  closely  from 
day  to  day,  and  if  a  circumscribed  abscess  forms  to  drain  it. 

Another  difficulty  encountered  in  the  treatment  of  children  is  their  fear 
of  the  stomach  tube.  It  is  important  to  employ  gastric  lavage,  but  many 
willful  and  badly  brotight-up  children  will  struggle  so  violently  against  its 
use  that  even  with  cocain  anesthesia  one  may  not  be  able  to  accomplish  the 
task  without  danger  of  injuring  the  patient  because  of  the  struggle  required. 
By  pinning  the  child  into  a  large  sheet  which  passes  around  the  entire  body 
from  its  neck  to  its  feet  and  placing  the  child  on  its  right  side,  it  is  usually 
possible  to  make  gastric  lavage  safely. 

To  a  slighter  extent  the  same  difficulties  are  sometimes  encountered  in 
rectal  feeding. 

The  most  important  point,  however,  is  in  dispelling  the  idea  that  a  se- 
vere pain  in  the  region  of  the  stomach  in  children,  coming  on  after  taking 
indigestible  food,  is  clue  to  gastritis  and  is  consequently  of  little  importance, 
because  so  often  a  careful  examination  will  demonstrate  it  to  be  a  gangrenous 
or  perforated  appendicitis.  This  condition  frequently  occurs  in  children  not 
more  than  four  years  of  age.  We  have  seen  a  number  of  cases  much  young- 
er, one  as  young  as  seven  months,  and  the  accompanying  history  of  a  case 
observed  by  Dr.  W.  P>.  Helm,  of  Rockford,  Illinois,  which  is  quoted  because 
of  its  unusual  interest,  shows  that  it  may  occur  in  those  still  younger. 

This  patient,  a  boy  three  months  old,  was  seen  by  Dr.  Helm,  January  5, 
1902.  He  had  suffered  almost  constantly  since  birth,  crying  much  of  the 
time,  night  and  day.  Frequent  tenesmus,  although  bowels  were  easily  regu- 


GENERAL    SURGERY    OF    THE    ABDOMEN  307 

lated.  The  mother's  milk  did  not  agree  and  various  prepared  foods  were 
tried.  The  child  took  food  ravenously,  but  never  seemed  satisfied.  There 
was  no  gain  in  weight  and  some  fever  persisted  most  of  the  time.  When 
the  child  was  five  weeks  of  age  the  local  physician  was  called  and  detected  a 
right  oblique  inguinal  hernia.  There  was  apparently  no  trouble  in  reducing 
it  and  he  tried  various  forms  of  retentive  apparatus.  Still  the  crying,  strain- 
ing and  fever  continued.  Seven  weeks  later  the  patient  began  to  fail  rapidly, 
and  Dr.  Helm  found  it  with  a  temperature  of  103°  F.  and  pulse  varying  from 
160  to  190.  The  child  weighed  only  eight  pounds  and  still  cried  most  of  the 
time.  There  was  a  hernial  protrusion  the  size  of  a  small  hen's  egg.  The 
bulk  of  the  mass  could  be  readily  returned,  but  a  small  object  in  the  inguinal 
canal  remained.  It  seemed  like  an  undescended  testicle,  but  both  of  these 
organs  were  found  to  be  in  the  scrotum.  Repeated  trials  failed  to  return  it 
to  the  abdomen,  so  an  operation  was  advised.  On  opening  the  canal  the 
doctor  found  that  the  reducible  portion  was  the  head  of  the  colon,  and  the 
irreducible  part  was  the  appendix,  slightly  adherent  and  greatly  congested. 
He  removed  the  appendix  and  closed  the  canal  by  the  Bassini  method.  The 
pain  was  apparently  lessened  at  once,  the  fever  disappeared  on  the  third  day 
and  the  child  gained  two  pounds  during  the  first  ten  days  and  made  an  unin- 
terrupted recovery.  It  seems  as  though  in  this  case,  judging  from  the  his- 
tory, the  appendicitis  may  have  been  congenital. 

In  connection  with  appendicitis  in  children,  we  believe  it  would  be 
best  to  lay  down  the  rule  that  in  every  instance  a  child  should  be  subjected 
to  a  careful  physical  examination  when  suffering  from  digestive  distur- 
bance, or  from  pain  in  the  abdomen  from  any  other  supposed  cause. 

Many  of  these  children  give  a  history  of  perverted  appetites  and  of  feel- 
ing sick  or  nauseated  after  meals  for  some  time  before  the  acute  attack. 

APPENDICITIS  IN   OLD  PEOPLE. 

Fortunately  it  is  but  seldom  that  acute  appendicitis  occurs  in  those  very 
advanced  in  years.  We  have  seen  one  case  of  perforative  appendicitis  in  a 
woman  sixty-eight  years  of  age. 

in  the  treatment  of  these  cases  the  fact  that  old  people  do  not  well  bear 
confinement  to  bed  in  the  recumbent  position  should  be  borne  in  mind.  These 
patients  should  be  placed  in  a  semi-sitting  posture  in  order  to  prevent  hypo- 
static  congestion  of  the  lungs.  If  it  seems  at  all  safe  it  is  well  to  operate  these 
cases  at  once  in  order  to  shorten  their  confinement  as  much  as  possible.  But 
these  patients  are  usually  very  obese,  which  still  further  reduces  their  chances 
of  recovery.  It  is  consequently  necessary  in  every  given  instance  for  the  sur- 
geon to  choose  between  two  evils,  and  the  better  his  judgment  the  more  like- 
ly he  will  be  to  choose  wisely.  If  the  operation  be  postponed  it  is  well  to 
reduce  the  amount  of  fat  in  the  abdominal  wall  of  obese  patients  by  proper 
treatment  and  to  remove  the  appendix  after  the  patient  has  recovered  from 
the  acute  attack.  The  method  for  reducing  the  weight  in  obese  patients  is 
discussed  fully  in  another  section. 

COMPLICATIONS  OF  APPENDICITIS. 

Any  condition  which  may  result  from  infection,  either  direct  or  meta- 
static,  may  result  as  an  immediate  complication  of  appendicitis.  Of  these  the 
most  common  is  circumscribed  or  diffuse  peritonitis,  with  or  without  the 


308  GENERAL    SURGERY    OF    THE    ABDOMEN 

formation  of  abscess.  This  complication,  as  has  been  stated  before,  is  greatly 
reduced  in  its  importance  if  neither  food  or  cathartics  are  given  from  the  be- 
ginning, because  this  eliminates  the  mechanical  distribution  of  infectious  ma- 
terial by  means  of  peristalsis.  It  also  prevents  the  disturbance  of  septic 
thrombi,  which  may  be  present  in  the  veins  at  the  seat  of  inflammation,  and 
which  might  be  loosened  were  food  and  gas  forced  through  the  ileo-cecal 
valve ;  consequently  metastatic  infection  is  also  greatly  reduced  in  this  way. 
Metastatic  abscesses  complicating  acute  appendicitis  may  develop  at  any 
point  in  the  body  and  should  be  treated  as  though  they  had  occurred  in  con- 
nection with  the  primary  infection. 

Many  other  complications  may  take  place,  because  the  presence  of  an 
acute  or  chronic  appendicitis  naturally  does  not  preclude  the  occurrence  of  any 
other  pathological  condition  which  might  be  present  in  a  patient  not  suffer- 
ing from  appendicitis. 

Strangulated  Hernia. 

A  considerable  number  of  cases  of  acute  appendicitis  complicating 
strangulated  hernia  have  been  reported.  We  have  encountered  gangren- 
ous appendices,  both  in  strangulated  femoral  and  inguinal  hernise,  and  in 
one  case  of  irreducible  umbilical  hernia. 

We  have  also  operated  upon  one  case  of  inguinal  hernia  which  was  com- 
plicated with  suppurative  epididymitis  and  orchitis,  together  with  an  acute 
suppurative  appendicitis  in  a  case  of  cryptorchism.  In  this  case  the  cecum 
was  so  low  that  by  lengthening  the  herniotomy  incision  upwards  by  dilatation 
it  was  possible  to  remove  the  appendix  through  this  opening.  An  orchidec- 
tomy  was  performed,  the  wound  drained  and  tamponed  with  iodoform  gauze 
for  a  week,  then  it  was  sutured  secondarily.  The  result  was  perfect. 

Typhoid  Fever. 

In  cities  where  typhoid  fever  is  endemic  it  is  not  a  very  uncommon  oc- 
currence to  find  difficulty  in  making  a  differential  diagnosis  between  typhoid 
fever  and  a  mild  attack  of  appendicitis,  or  between  the  presence  of  a  perfora- 
tive  appendicitis  and  a  perforated  typhoid  ulcer.  In  case  the  differential  diag- 
nosis between  acute  appendicitis  and  perforative  typhoid  ulcer  cannot  be  made 
positively  an  abdominal  section  is  indicated,  because  if  the  former  condition 
is  found,  this  treatment  is  proper  while  if  the  latter  exists  non-operative 
treatment  would  almost  certainly  bring  about  a  fatal  result. 

The  Widal  test  may  be  used  for  making  a  differential  diagnosis,  but  if 
the  patient  has  had  typhoid  fever  at  some  previous  time  the  Widal  test  will 
often  be  positive,  and  this  will  be  misleading.  Moreover  it  is  often  not 
wise  to  postpone  operative  treatment  long  enough  to  make  this  test.  It  is 
also  to  be  borne  in  mind  that  the  Widal  test  is  applicable  only  to  advanced 
cases  of  typhoid  fever,  hence,  its  value  is  greatly  reduced. 

In  several  instances  we  have  observed  patients  suffering  from  plainly 
marked  attacks  of  acute  appendicitis  in  which  a  typical  attack  of  typhoid 
fever  followed  immediately.  In  each  of  these  cases  the  patient  had  con- 
sumed great  quantities  of  infected  water  during  the  beginning  of  his  sick- 
ness. The  fever  accompanying  the  appendicitis  caused  severe  thirst,  and  the 
great  quantity  of  water  containing  typhoid  bacilli  consumed  during  the  time 
had  undoubtedly  brought  about  the  typhoid  infection. 

\Ve  have,  of  course,  seen  many  cases  of  simple  appendicitis  which 
had  been  diagnosed  typhoid  fever,  and  vice  versa,  but  the  cases  referred  to 
above  did  not  belong  to  this  class. 


GENERAL    SURGERY    OF    THE    ABDOMEN  309 

In  some  locations,  especially  in  great  cities,  in  which  a  large  proportion 
of  the  population  regularly  drinks  unsterilized  water  infected  with  typhoid 
bacilli,  it  is  wise  to  bear  in  mind  the  fact  that  typhoid  fever  and  appendi- 
citis may  occur  at  the  same  time  in  the  same  patient.  Of  course,  the  same 
thing  might  happen  by  accident  with  almost  all  of  the  other  intra-abdominal 
conditions.  We  have  personally  encountered  a  renal  calculus,  an  extra- 
uterine  pregnancy,  a  gastric  ulcer,  as  well  as  all  the  varieties  of  tumors  oc- 
curring in  the  uterus  and  adnexa,  in  connection  with  acute  appendicitis.  It 
is  likely  that  in  each  case  the  fact  was  due  simply  to  a  coincidence  and  that 
no  causal  relation  existed  between  the  two  conditions. 

Floating  Kidney. 

The  presence  of  an  abnormal  mobility  of  the  right  kidney,  either  with 
or  without  general  enteroptosis,  is  not  at  all  uncommonly  found  in  connec- 
tion with  chronic  recurrent  appendicitis.  It  is  possible  that  the  increased 
intra-abdominal  pressure  which  has  to  be  employed  to  overcome  the  obstruc- 
tion to  the  passage  of  gas  and  feces  through  the  ileo-cecal  valve  in  these 
cases  may  be  responsible  for  the  mobility  of  the  kidney,  or  it  may  simply  be 
a  coincidence. 

In  many  there  are  extensive  adhesions  which  interfere  seriously  with 
the  fecal  circulation,  causing  the  intestines  and  the  stomach  to  be  constantly 
distended  with  gas,  and  this  may  help  to  account  for  the  mobility  of  the  kid- 
ney. 

Thrombo-Phlebitis. 

Occasionally  in  cases  of  appendicitis  which  have  not  been  operated,  and 
more  frequently  following  operation,  there  is  a  thrombo-phlebitis  of  the  ex- 
ternal iliac  vein.  Ordinarily  the  condition  does  not  materially  interfere 
with  the  recovery.  The  same  precautions  should,  however,  be  employed 
as  in  a  thrombo-phlebitis  from  any  other  cause.  If  a  small  portion  of  the 
thrombus  is  displaced,  it  is  likely  to  cause  serious  trouble  and  may  even  give 
rise  to  thrombosis  of  the  pulmonary  artery,  causing  sudden  death.  In  this 
condition  the  greatest  danger  to  the  patient  results  from  the  fact  that  lay- 
men are  likely  to  rub  or  massage  the  affected  part  and  thus  may  loosen  a 
thrombus. 

The  part  should  be  placed  at  absolute  rest  and  under  no  circumstances 
should  rubbing  or  massage  be  permitted  over  the  affected  area. 

Pregnancy. 

A  complication  which  is  usually  mistaken  for  puerperal  fever  results 
from  the  coincidence  of  an  acute  gangrenous  or  perforative  appendicitis 
with  the  delivery  of  a  pregnant  woman.  We  have  personally  observed  a  num- 
ber of  cases  in  which  the  differential  diagnosis  could  not  be  positively  made, 
but  in  four  cases  we  were  able  to  demonstrate  gangrenous  appendices  at 
the  operation,  which  should  be  made  at  once  if  a  positive  diagnosis  can  ob- 
tain, and  it  seems  reasonable  to  add  that  if  the  absence  of  acute  gangrenous 
appendicitis  cannot  be  made  with  certainty,  operation  is  justifiable. 

DIFFUSE  PERITONITIS. 

Of  all  the  complications  of  acute  appendicitis  the  most  dangerous  is 
diffuse  peritonitis.  Moreover,  acute  perforative  and  gangrenous  appendicitis 
and  its  treatment  by  the  use  of  cathartics,  together  with  the  administration 


3IO  GENERAL    SURGERY    OF    THE   ABDQMEN 

of  some  form  of  food  by  mouth,  or  the  operation  of  these  cases  after  be- 
ginning diffuse  peritonitis  has  become  established,  which  occurs  usually  in 
severe  cases  from  the  second  to  the  fifth  day,  have  given  rise  to  more  in- 
stances of  diffuse  peritonitis  than  all  other  causes  combined ;  hence  it  may 
be  proper  to  discuss  the  subject  at  this  point  and  to  emphasize  especially  the 
steps  required  for  its  prevention. 

PREVENTION  AND  INHIBITION   OF  PERITONITIS. 

At  the  very  beginning  it  seems  important  to  emphasize  the  fact  that 
treatment  must  be  directed  almost  entirely  toward  prevention  and  inhi- 
bition of  peritonitis,  because  this  will  reduce  the  mortality  from  this  dis- 
ease enormously.  Physicians  in  general  practice  who  have  appreciated 
this  fact  have  almost  completely  eliminated  deaths  from  peritonitis  in 
their  practice,  while  others  whose  attention  has  been  directed  toward  the 
cure  of  peritonitis  have  succeeded  in  reducing  their  mortality  from  this 
disease  only  to  a  very  slight  extent. 

Prevention  must  depend  largely  upon  a  careful  early  diagnosis,  and 
inhibition  upon  early  treatment,  in  cases  in  which  a  circumscribed  or  a  be- 
ginning diffuse  peritonitis  exists  when  the  patient  comes  under  the  phy- 
sician's care,  by  definitely  planned  methods  which  will  prevent  diffusing 
septic  material  from  its  circumscribed  location  to  other  portions  of  the  peri- 
toneal cavity. 

There  must,  of  course,  always  be  a  certain  percentage  of  mortality  be- 
cause some  cases  will  not  reach  the  care  of  the  physician  until  they  are 
beyond  the  period  at  which  prevention  or  inhibition  is  possible,  but  this 
class  is  constantly  decreasing  because  physicians  are  becoming  more  thor- 
ough in  examining  their  patients,  and  laymen  are  learning  the  importance 
of  early  intervention.  There  will  also  always  be  a  percentage  of  mortality 
in  cases  in  which  the  primary  infection  is  overwhelming,  as  in  some  cases 
of  perforation  of  gastric,  duodenal  or  typhoid  ulcers,  or  ruptured  gall  blad- 
der, although  in  all  of  these  early  closure  of  the  perforation,  spong- 
ing away  the  extravasated  substance  and  thorough  drainage  has  reduced 
the  loss  from  this  source  to  a  marked  degree.  Moreover,  typhoid  perfora- 
tions are  becoming  very  scarce  in  communities  which  are  sufficiently  civ- 
ilized not  to  drink  water  infected  with  sewerage,  and  among  those  who  will 
not  permit  their  food  to  be  infected  by  flies. 

The  mortality  from  peritonitis  at  the  present  time  is  by  far  greatest 
in  cases  in  which  the  infection  comes  from  the  vermiform  appendix  and 
in  those  of  puerperal  origin. 

Medical  literature  shows  absolutely  that  there  is  no  form  of  treat- 
ment of  much  use  in  peritonitis  which  is  so  far  advanced  that  the  patient 
is  suffering  to  a  marked  degree  from  general  sepsis.  We  might  as  well 
think  of  saving  a  wooden  building  after  fire  has  partially  destroyed  all  the 
walls  and  floors.  It  is  unreasonable  to  expect  good  results  under  these 
conditions. 

Our  attention  must  be  directed  first  toward  prevention,  which  is  pos- 
sible in  most  cases,  because  peritonitis  results  from  conditions  which  can 
be  recognized  and  permanently  relieved  before  they  have  given  rise  to 
peritonitis  by  making  a  careful  physical  examination  in  every  case  suffer- 
ing from  intra-abdominal  conditions.  A  perforation  of  the  gall  bladder 


GENERAL    SURGERY    OF    THE    ABDOMEN  ,  31 1 

is  always  preceded  by  gastric  disturbances  which  should  result  in  a  physical 
examination,  which,  in  turn,  should  establish  a  diagnosis  of  cholecystitis  or 
cholelithiasis.  An  operation  for  the  relief  of  this  condition  would  prevent 
the  perforation  and  peritonitis. 

The  same  can  be  said  of  other  conditions  which  later  result  in  peri- 
tonitis. 

Value  of  the  Physical  Examination. 

No  physician  has  a  right  to  prescribe  for  the  relief  of  any  intra- 
abdominal  condition  without  having  made  a  physical  examination. 

The  calamity  which  may  follow  the  crime  of  a  superficial  examination 
in  chronic  cases,  after  weeks  or  months,  may  follow  after  days  or  hours 
in  acute  cases. 

By  giving  something  for  the  relief  of  indigestion  in  the  chronic  case, 
without  a  physical  examination  demonstrating  the  presence  of  a  gastric  or 
duodenal  ulcer  or  gallstones,  the  physician  may  be  responsible  for  the  peri- 
tonitis which  may  occur  weeks  or  months  later  as  a  result  of  perforation. 
Quite  as  certainly,  by  giving  a  cathartic  for  acute  indigestion  without  a 
physical  examination  in  a  case  of  gangrenous  appendicitis,  he  may  cause  a 
distribution  of  the  infectious  material  over  the  entire  peritoneal  cavity 
by  stimulating  peristalsis,  producing  a  diffuse  peritonitis.  This  in  turn 
may  destroy  the  life  of  the  patient  in  a  few  days.  For  a  fairly  trained 
diagnostician  it  is  possible  to  recognize  all  of  these  conditions,  whether  they 
be  acute  or  chronic,  in  time  to  prevent  or  inhibit  peritonitis  if  he  makes  a 
careful  examination  when  the  patient  first  comes  under  his  care.  At  the 
end  of  this  chapter  a  number  of  conclusions  will  be  found,  which  will  con- 
tain the  various  elements  to  be  considered  in  planning  the  prevention  and 
inhibition  of  peritonitis.  At  this  point  the  part  played  in  the  production 
and  acceleration  of  peritonitis  by  the  use  of  cathartics  will  be  discussed 
more  extensively.  Undoubtedly,  many  patients  lose  their  lives  from  gen- 
eral peritonitis  because  they  were  given  either  cathartics  or  food,  or  both, 
by  mouth  after  the  beginning  of  the  peritoneal  infection.  In  the  very  large 
number  of  cases  which  have  come  under  our  personal  observation,  there  has 
not  been  a  single  instance  of  death  from  peritonitis  in  which  neither  cathar- 
tics nor  food  had  been  given  by  mouth  after  the  beginning  of  the  attack, 
which  seems  to  be  a  most  important  observation. 

The  Introduction  of  Cathartics  in  the  Treatment  of  Peritonitis. 

Thirty-five  years  ago  the  phenomenal  success  in  abdominal  surgery 
experienced  by  Lawson  Tait  was  attributed  by  many  to  the  fact  that  he 
administered  cathartics  to  his  patients  directly  after  performing  laparoto- 
mies,  and  the  fact  that  his  patients  regularly  recovered  without  symptoms 
of  peritonitis  after  ordinary  abdominal  operations  performed  for  non- 
septic  conditions,  while  other  surgeons  lost  similar  patients  constantly  from 
peritonitis  at  this  period,  led  to  the  conclusion  that  cathartics  prevent  peri- 
tonitis. He  says,  in  the  Hastings  essay  for  1873,  ''The  administration 
of  laxatives  within  a  few  hours  after  the  operation  is  becoming  quite  a 
common  practice  with  me,  this  innovation,  in  my  opinion,  being  possibly 
conducive  in  some  measure  to  my  increased  success." 

This  theory  that  cathartics  can  prevent  or  inhibit  peritonitis  appeared 
very  frequently  in  essays  and  in  textbooks  during  the  following  quarter 
of  a  century,  although,  in  the  meantime,  every  surgeon  had  learned  the  fact 


312  GENERAL    SURGERY    OF    THE    ABDOMEN 

that  the  absence  of  peritonitis  following  Tait's  operations  was  due  to  the 
circumstance  that  he  was  a  clean,  rapid  surgeon,  who  neither  infected 
his  patients  nor  unnecessarily  traumatized  the  peritoneum,  and  that  be- 
cause neither  infection  nor  trauma  were  present,  the  cathartics  he  gave  were 
harmless. 

During  these  years  many  medical  books  and  articles  contained  state- 
ments similar  to  the  following  referring  to  the  treatment  of  acute  appen- 
dicitis. It  will  not  be  necessary  to  quote  from  more  than  one  of  the  best 
authorities  who  now  never  gives  either  cathartics  or  food  in  acute  infection 
of  any  portion  of  the  peritoneal  cavity  because,  during  this  period,  all  of 
the  best  authorities,  like  Deaver,  Murphy,  Minter,  Fowler,  Morris,  made 
similar  statements  in  their  books.  "The  bowel  must  be  kept  clean  from 
irritating  fecal  matter,  by  enemata  if  possible,  by  a  good  cathartic  if  nec- 
essary." Evidence  is  not  wanting  of  successful  results  obtained  by  medi- 
cal treatment,  especially  in  the  use  of  saline  purgatives." 

Only  patients  in  whom  the  infection  was  still  confined  to  the  appendix 
and  those  in  whom  the  infection  had  been  sufficiently  circumscribed  by 
strong  adhesions  to  make  dissemination  of  septic  material  impossible,  which, 
according  to  the  careful  studies  of  Stanton.  rarely  occurs  before  the  seventh 
day,  furnished  safe  cases  for  this  treatment. 

At  that  time  this  surgeon's  mortality  in  operations  for  appendicitis 
was  almost  10  per  cent.,  and  since  prohibiting  all  forms  of  food  and  cathar- 
tics by  mouth,  and  giving  normal  salt  solution  by  rectum,  his  mortality  has 
been  reduced  to  less  than  one-fourth  of  this  percentage  in  precisely  the 
same  class  of  cases. 

Mode  of  Action  of  Cathartics. 

In  cases  in  which  the  primary  infection  comes  from  a  circumscribed 
point  like  the  appendix,  or  a  leaking  pus  tube,  or  a  nearly  perforated  gas- 
tric, duodenal  or  typhoid  ulcer  with  slightly  adherent  omentum  covering 
the  point  of  danger,  the  conditions  are  fair  for  obtaining  a  circumscribed 
instead  of  a  diffuse  infection.  The  same  is  true  in  case  of  a  gall  bladder 
with  a  gangrenous  mucous  lining. 

In  case  of  the  appendix  and  the  Fallopian  tube,  the  cecum,  sigmoid 
and  the  omentum  are  likely  to  confine  the  infection  to  the  pelvic  portion 
of  the  abdominal  cavity.  In  all  of  the  other  instances  the  burden  of  the 
work  of  protection  falls  upon  the  omentum,  but  so  long  as  the  infection 
is  in  one  circumscribed  location,  the  entire  free  portion  of  the  omentum 
can  and  will  arrange  itself  about  this  point  and  will  prevent  the  infec- 
tious material  from  passing  on  to  other  portions  of  the  peritoneum.  All  of 
the  physiological  forces  become  active  to  prevent  the  escape  of  this  septic 
material  to  other  portions  of  the  peritoneal  cavity.  The  colon  becomes 
filled  with  gas  and  acts  as  a  cofferdam.  The  small  intestines,  if  not  disturbed 
by  cathartics  or  food,  form  an  embankment  about  the  diseased  area. 

These  conditions  have  been  observed  innumerable  times  by  surgeons 
who  have  operated  in  acute  cases. 

The  nausea  prevents  the  patient  from  taking  food  unless  this  is  forced 
upon  him  by  some  foolish  friend  or  unless  it  is  prescribed  by  some  incompe- 
tent physician. 

The  abdominal  walls  become  rigid  and  form  an  anterior  splint.  Every- 
thing is  as  favorable  as  can  be  for  the  process  of  repair,  which  consists  in 
the  concentration  of  the  activity  of  millions  of  leucocytes  in  the  infected  area 


GENERAL    SURGERY    OF    THE    ABDOMEN  313 

and  the  production  of  antibodies  in  the  blood  and  the  limitation  of  nutri- 
tion of  the  septic  micro-organisms  to  an  area  in  which  they  will  soon  be- 
come reduced  in  virulence. 

It  is  true  that  the  alimentary  canal  may  contain  septic  material,  but 
this  will  soon  be  excreted  through  the  stomach  and  can  be  readily  removed 
by  the  use  of  gastric  lavage.  If  no  further  food  of  any  kind  is  given  by 
mouth,  the  small  intestines  will  soon  be  free  from  septic  material,  and  gas- 
tric lavage  applied  once  or  twice  will  usually  suffice  to  remove  the  septic 
material  excreted  into  the  stomach,  although  in  rare  instances  it  is  neces- 
sary to  repeat  this  lavage  several  times  a  day  for  several  days. 

Were  one  to  continue  placing  food  in  the  stomach  during  the  progress 
of  the  disease,  then  there  might  be  some  doubt  as  to  the  choice  between 
the  two  evils  of  leaving  a  quantity  of  decomposing  substance  in  the  ali- 
mentary canal  to  poison  the  patient,  or  forcing  it  out  by  means  of  a  ca- 
thartic and  incidentally  killing  the  patient  by  carrying  the  septic  material 
from  this  circumscribed  area  to  the  other  peritoneal  surfaces  by  the  peris- 
talsis caused  by  the  cathartic. 

Since  it  is  possible  to  supply  the  necessary  amount  of  nourishment 
by  rectal  alimentation  and  a  sufficient  amount  of  fluid  by  the  continuous 
normal  salt  solution  introduced  by  the  drop  method  into  the  rectum,  ac- 
cording to  the  system  originated  by  Murphy,  or  by  any  one  of  the  numerous 
methods  which  have  been  described  by  others,  there  is  no  reason  why  one 
should  risk  harm  by  introducing  food  or  cathartics  by  mouth.  No  good  can 
come  from  it  because  it  is  not  needed.  That  harm  does  come  from  it  is  not 
only  plain  from  the  theoretical  reasons,  but  has  been  demonstrated  in  hun- 
dreds of  cases. 

This  applies  to  all  cases  without  regard  to  the  form  of  surgical  treat- 
ment that  may  be  chosen  in  any  given  case. 

Whatever  surgical  treatment  may  be  contemplated  in  case  of  any  form 
of  existing  peritonitis,  the  results  must  be  better  if  the  infection  is  not  dif- 
fused by  peristalsis.  There  can,  therefore,  be  no  reason  why  peristalsis  should 
be  initiated  by  the  use  of  cathartics.  Even  the  smallest  amount  of  cathartic 
may  change  a  harmless  circumscribed  infection  into  a  serious  diffuse  peri- 
tonitis. 

One  demonstrable  change  consists  in  the  rapid  increase  in  leucocytosis 
even  after  the  administration  of  a  small  amount  of  cathartics.  One-tenth 
grain  of  calomel  with  one  grain  of  soda  may  increase  leucocytosis  several 
thousand  within  a  few  hours,  and  the  same  is  true  of  other  cathartics  and 
also  of  enemata,  except  when  given  by  the  drop  method.  We  have  had  an 
opportunity  to  observe  this  in  a  hospital  whose  beds  are  open  to  the  gen- 
eral practitioners  of  the  community  in  which  it  is  located.  Some  of  these 
practitioners  give  cathartics  habitually  as  a  form  of  initiative  treatment 
while  they  are  trying  to  think  what  form  of  treatment  is  indicated.  This 
has  given  us  an  opportunity  to  study  the  effects  of  cathartics  upon  the 
leucocytosis  in  these  cases. 

A  former  assistant.  Dr.  John  L.  Yates,  has  proven  conclusively,  by 
a  large  series  of  experiments  upon  animals,  that  infectious  material  is 
rapidly  diffused  by  the  administration  of  food  or  cathartics,  because  of  the 
establishment  of  peristalsis.  Injecting  lampblack  into  the  abdominal  cavity. 
he  found  that  this  remained  in  a  circumscribed  location  so  long  as  the  in- 
testines were  at  rest ;  but  upon  the  administration  of  cathartics  it  is  rapidly 


314  GENERAL    SURGERY    OF    THE    ABDOMEN 

diffused  over  the  entire  peritoneal  cavity.  The  same  was  true  of  septic 
material  introduced  in  the  same  manner. 

Constipation  is  looked  upon  rightly  as  a  cause  of  ill  health ;  conse- 
quently it  is  but  natural  that,  counting  upon  the  law  of  probabilities,  a 
physician  or  a  layman  who  gives  a  cathartic  in  every  case,  with  or  without 
having  previously  made  a  diagnosis,  will  have  fair  results  in  most  patients 
who  are  not  suffering  from  peritonitis.  Moreover,  in  cases  in  which  there 
is  not  as  yet  a  circumscribed  peritonitis,  especially  in  catarrhal  appendicitis, 
the  patient  feels  better  after  the  use  of  a  cathartic  and,  as  there  is  no  septic 
material  present  to  be  diffused  throughout  the  peritoneal  cavity,  no  harm 
can  come  to  this  class  of  patients. 

If  one  can  be  absolutely  certain,  therefore,  in  any  given  case,  that 
there  is  no  circumscribed  infection,  a  cathartic  can,  of  course,  be  given 
safely  in  that  case.  If  no  harm  comes  from  it,  the  diagnosis  has  been  con- 
firmed, but  whenever  there  is  the  slightest  doubt  it  would  be  foolish  to 
take  such  a  risk  for  the  sake  of  confirming  a  diagnosis.  As  a  general  rule 
it  may  be  stated  that  in  all  doubtful  cases,  even  if  the  doubt  be  ever 
so  slight,  a  cathartic  should  never  be  given  because  in  the  given  case  in 
which  it  is  harmless  it  is  not  needed,  as  the  bowels  will  be  spontaneously 
evacuated,  and  in  the  other  cases  cathartics  are  contraindicated. 

That  a  cathartic  is  safe  in  only  a  very  small  percentage  of  cases  was 
proven  by  Murphy's  statistics  of  1895,  which  showed  that  in  94  per  cent, 
of  cases  of  acute  appendicitis  pus  was  found  outside  the  appendix  at  the 
time  they  came  under  treatment.  It  is  plain  that  the  6  per  cent,  in  whom 
the  infection  is  still  confined  to  the  appendix  will  all  recover  under  proper 
surgical  treatment,  and  the  94  per  cent,  in  whom  the  infection  is  already 
beyond  the  tissues  of  the  appendix  must  be  exposed  to  great  risk  if  peristal- 
sis is  caused  by  the  administration  of  cathartics. 

Effect  of  Cathartics   in  Cases  of  Mechanical   Obstruction   of  the  Intestine. 

However  harmful  it  may  be  to  administer  cathartics  in  cases  suffering 
from  circumscribed  peritonitis,  it  is  still  more  harmful  to  administer  these 
remedies  in  cases  suffering  from  mechanical  obstruction  of  the  intestines, 
no  matter  whether  this  be  due  to  strangulated  hernia,  volvulus,  Meckel's 
diverticulum,  constricting  bands  of  adhesion,  intussusception,  kinking  of  the 
intestines,  impacted  gallstone,  impacted  submucous  lipoma  or  fibroma  in 
the  intestinal  wall  or  obstruction  due  to  malignant  growths  in  the  intes- 
tinal wall  or  pressing  upon  it  from  the  outside. 

In  every  case  in  which  there  is  even  a  suspicion  of  mechanical  obstruc- 
tion of  the  bowel,  gastric  lavage  should  be  instituted  at  once  and  absolutely 
nothing  should  be  given  by  mouth. 

The  intestine  above  the  point  of  obstruction  suffers  so  severely  as  a 
result  of  the  pressure  from  the  peristaltic  action  caused  by  cathartics  that 
the  walls  become  permeable  to  the  passage  of  septic  material,  which  is 
proven  by  the  presence  of  micro-organisms  in  the  peritoneal  fluid,  and 
the  mortality  is  at  least  four  times  greater  in  cases  that  have  received 
cathartics  than  in  those  that  have  received  none.  In  many  cases  the  in- 
testine may  even  be  perforated  above  the  constriction  as  a  result  of  the 
use  of  cathartics.  All  of  these  conditions  we  have  encountered  many  times 
in  practice. 


GENERAL    SURGERY    OF    THE    ABDOMEN  315 

Puerperal  sepsis  and  post-operative  sepsis  must,  of  course,  be  elim- 
inated by  proper  prophylaxis. 

Although  convinced  that  abstaining  from  the  use  of  cathartics 
alone  in  cases  of  incipient  peritonitis  is  the  most  important  means  of 
inhibiting  this  disease,  still  we  believe  that  it  is  most  important  to  bear  in 
mind  all  of  the  following  conclusions  and  that,  when  these  have  been 
thoroughly  applied  in  practice,  deaths  from  peritonitis  will  be  almost  en- 
tirely eliminated.  These  conclusions  are  quite  as  applicable  to  cases  which 
are  treated  surgically  as  those  treated  without  surgical  intervention. 

It  would  be  most  unfortunate  if,  by  directing  attention  particularly 
to  the  harmful  effects  of  cathartics  in  peritonitis,  this  section  should  lead 
especially  the  general  practitioner  to  think  that  this  is  the  only  dangerous 
form  of  treatment,  because  the  errors  pointed  out  in  the  following  con- 
clusions have  also  destroyed  an  enormous  number  of  human  lives,  and 
by  constantly  keeping  them  in  mind  any  general  practitioner  can  reduce  his 
mortality  decidedly. 

Conclusions. 

1.  A    careful    physical    examination    should    always    be    made     in 
patients  suffering  from  gastric  disturbances,  nausea,  vomiting,  gaseous  dis- 
tention  or  pain  in  any  portion  of  the  abdomen,  so  that  an  early  diagnosis 
can  be  made.     In  acute  cases  violent  manipulations  are  dangerous  and  not 
necessary    during    examination.      They    may    cause    a    diffusion    of    septic 
material. 

2.  A  diagnosis  of  chronic  appendicitis,  gastric  or  duodenal  ulcer  or 
gallstones   should   be   made   through   a   careful    study   of   the   history   and 
physical  examination,  and  relieved  by  proper  treatment  before  a  perforation 
is  possible. 

3.  Patients    suffering    from    intestinal    obstruction,    whether    this    be 
due  to  strangulated  hernia,  constriction  by  bands  or  adhesions,  volvulus,  in- 
tussusception or  kinking  of  intestine,   Meckel's  diverticulum,  gallstone  or 
carcinoma,  should  be  operated  at  once  and  they  should  never,  under  any 
circumstances,  receive  either  cathartics  or  food"  by  mouth  after  this  con- 
dition is  even  suspected. 

4.  Gastric  lavage  should  be  employed  in  these  cases  at  once  and  again 
immediately  before  operation,   and   it   is  well   to   leave   the   stomach   tube, 
preferably  the  form  invented  by  Kausch.  in  the  stomach  to  drain  out  any 
intestinal  fluid  which  may  regurgitate  during  the  operation.     Many  of  these 
cases  can  be  operated  under  local  anesthesia. 

5.  Opium  in  any  form  should  never  be  given  before  a  diagnosis  has 
been  made,  and  never  in  the  presence  of  any   form  of  peritonitis,  unless 
gastric  lavage  has  been  done,  and  the  introduction  of  every  form  of  nour- 
ishment and  cathartics  by  mouth  is  absolutely  prohibited.     This  applies  to 
even  the  simplest  forms  of  liquids,  like  beef  tea  or  broth,  and  also  to  the 
use  of  champagne  and  other  stimulants. 

6.  This    applies    quite    to    the    same    extent    to    post-operative    treat- 
ment. 

7.  In  military  surgery  it  is  most  important  as  a  prophylactic  meas- 
ure that  soldiers  enter  the  firing  line  with  empty  stomachs  and  intestines. 

8.  Abdominal   wounds   made   during   battle,   with    large   objects   like 
splinters  from  shells,  indicate  immediate  operation. 


3l6  GENERAL    SURGERY    OF    THE    ABDOMEN 

9.  Abdominal  wounds  inflicted  in  battle  by  small  calibre  bullets,  in 
the  absence  of  hemorrhage,  should  be  treated  by  absolute  rest ;  not  even 
water  should  be  given  by  mouth. 

10.  An  exception  should  be  made  in  cases  which  can  be  in  the  hands 
of  the  operating  surgeon  with  satisfactory  assistants  and  facilities  within 
two  hours  after  the  injury.    Under  these  conditions  an  immediate  abdominal 
section  is  indicated. 

11.  Gastric  lavage  should  be  done  at  once  in  every  patient  suffering 
from  any  form  of  peritonitis,  except  from  stomach  or  duodenal  perfora- 
tion, if  nausea  or  vomiting  or  gaseous  distension  is  present,  no  matter  what 
other  form  of  treatment  may  be  contemplated. 

12.  No  food  of  any  kind  whatever  and  no  cathartics  should  ever  be 
given  by  mouth  in  the  presence  of  peritonitis,  no  matter  what  other  form 
of  treatment  may  be  contemplated. 

13.  Even  water  by  mouth  should  be  prohibited  until   the  patient  is 
well  on  the  way  to  recovery. 

14.  Instillation  of  normal  salt  solution  by  the  drop  method,  by  rec- 
tum, as  introduced  by  Murphy,  or  by  some  other  safe  non-irritating  method, 
is  one  of  the  most  valuable  means  of  inhibiting  peritonitis.     It  is  well  to 
give  normal  salt  solution  continuously  from  one  to  two  hours  and  then  to 
interrupt  this  treatment  for  two  hours. 

15.  In  rare  cases  in  which  this  method  cannot  be  employed,  normal 
salt  solution  should  be  given  subcutaneously  in  quantities  of  500  to  1,000 
ccm.   sufficiently  often   to  overcome    thirst    and    keep    the    blood    vessels 
filled. 

16.  Large  enemata,  except  by  the  drop  method,  should  never  be  given 
in  the  presence  of  peritonitis. 

17.  In   order   to    prevent   post-operative   peritonitis,    it    is    important 
never  to  traumatize  the  intra-abdominal  organs  unnecessarily  during  opera- 
tion. 

18.  Much   less   handling  of  the   intestines   is  necessary   if   these   are 
not  distended  with  gas,  a  condition  which  can  best  be  secured  by  giving  the 
patient  two   ounces   of   castor   oil    on   the    day   before   the   operation,   but 
this  should  never  be  given  in  the  presence  of  even  the  slightest  amount  of 
peritonitis  of  any  form. 

19.  Gastric   lavage    following  abdominal    section    often   prevents    in- 
cipient peritonitis    from   progressing  by    inhibiting    peristalsis ;    it    should 
always  be  employed  in  the  presence  of  nausea  or  vomiting  or  gaseous  dis- 
tension. In  order  to  prevent  gagging,  it  is  well  to  spray  the  pharynx  thor- 
oughly with  a  2  per  cent,  solution  of  cocaine  ten  minutes  before  the  stomach 
tube  is  introduced. 

20.  In  acute  appendicitis  the  appendix  should  be  removed  before  the 
infection  has  extended  beyond  the  organ.     If  conclusion  No.   T  is  adhered 
to,  this  can  be  done  in  almost  every  case  with  almost  perfect  safety,  be- 
cause the  patient  can  then  be  placed  in  the  hands  of  a  competent  surgeon 
within  thirty-six  or  forty-eight  hours  from  the  beginning  of  the  attack. 

21.  In  subacute  and  chronic  appendicitis  the  appendix  should  be  re- 
moved before  it  has  an  opportunity  to  cause  an  acute  attack. 

22.  In  acute  appendicitis  which  has  been  carried  through  an  attack 
without  an  operation,  it  is  well  to  confine  the  patient  absolutely  to  a  liquid 
diet  until  his  appendix  has  been  removed. 


GENERAL    SURGERY    OF    THE    ABDOMEN  317 

23.  In  cases  of  acute  appendicitis,  either  perforative  or  gangrenous, 
which  have  received  some  form  of  food  or  cathartics  after  the  beginning  of 
the  attack,  which    reach   the   care   of   a   surgeon  too  late  for  a  safe  early 
operation  and  are  suffering  from  beginning  diffuse  peritonitis,  gastric  lavage, 
absolute  abstinence  from  food  and  cathartics  by  mouth  and  the  slow  in- 
stillation of  normal  salt  solution  by  rectum  are  indicated. 

24.  This  will  result  in  the  increase  of  resistance  against  infection  to 
such  an  extent  that  97  per  cent,  of  these  cases  of  perforative  or  gangrenous 
appendicitis  can  later  be  operated  with  safety. 

25.  Feeding  should  be  entirely  by  enemata,  preferably  consisting  of 
one   ounce   of   a   commercial   concentrated   liquid    food   dissolved   in   three 
ounces   of   normal   salt   solution   given   slowly   every   three  or   four  hours 
through  a  small  rubber  catheter  introduced  into  the  rectum  not  more  than 
three  inches. 

26.  From  ten  to  thirty  drops  of  deodorized  tincture  of  opium  should 
be  added  to  each  rectal  feeding,  until  there  is  no  longer  any  pain. 

27.  Placing  these  patients   in   the   Fowler  position  greatly   increases 
their  safety. 

28.  The  application  to  the  abdomen  of  a  large,  hot,  moist  dressing 
of  equal  parts  of  a  saturated  solution  of  boric  acid  and  alcohol  greatly  in- 
creases the  comfort  of  these  patients  and  prevents  harm   from  manipula- 
tions. 

29.  It  is  important  for  the  general  practitioner  and  the  general  pub- 
lic to  become  familiar  with  the  danger  of  giving  any  kind  of  nourishment 
or  cathartics  by  mouth  in  the  presence  of  impending  peritonitis  from  any 
cause,  and  that  this  applies  to  milk,  broth  and  other  forms  of  liquids  and 
even  to  water. 

The  repetitions  in  these  conclusions  are  intentional  because  it  has 
seemed  worth  while  to  cover  every  possible  point  so  completely  that  no  one 
taking  the  time  to  read  these  conclusions  carefully  could  be  in  doubt.  As 
stated  before,  these  conclusions  are  all  based  upon  the  observation  of  a  very 
large  number  of  cases  and  they  are  not  in  any  way  theoretical  as  they  all 
have  an  intensely  practical  foundation. 

TUBERCULAR    PERITONITIS. 
Typical  Case. 

The  patient  is  a  married  woman  thirty-two  years  of  age,  giving  the  fol- 
lowing history : 

Her  father  died  of  pulmonary  tuberculosis  at  the  age  of  fifty.  One  sis- 
ter died  from  the  same  cause  at  the  age  of  thirty.  Another  sister  is  suffer- 
ing from  the  same  disease  at  the  present  time.  The  patient  had  measles  as 
a  child  but  otherwise  has  had  good  health.  Her  menstruation  began  at  the 
age  of  fifteen  and  was  regular  but  somewhat  painful.  She  married  at  twen- 
ty-two ;  has  had  five  normal  pregnancies.  She  has  suffered  from  constipa- 
tion during  the  past  ten  years.  The  abdomen  has  been  distended  for  sev- 
eral years  and  she  has  suffered  from  eructations  of  gas.  About  four  months 
ago  fluid  was  first  discovered  in  the  abdominal  cavity.  She  was  then  put  to 
bed  and  received  internal  treatment,  but  the  accumulation  of  fluid  in  the  peri- 
toneal cavity  has  constantly  increased.  In  the  meantime  she  has  lost  ten 
pounds  in  weight.  She  has  occasional  pains  in  the  left  side  of  the  abdomen, 
lasting  a  few  hours  at  a  time.  The  abdomen  is  enlarged  to  the  size  of  a  six 


3l8  GENERAL    SURGERY    OF    THE    ABDOMEN 

months'  pregnancy,  but  is  flattened  and  there  is  a  prominence  of  the  umbili- 
cus. 

The  patient  is  sufficiently  nourished ;  her  tongue  is  clean ;  the  appetite 
fair ;  bowels  constipated ;  heart,  lungs,  liver  and  kidneys  normal ;  her  tem- 
perature is  normal ;  pulse  is  80,  regular  and  fairly  strong ;  abdomen  is  dis- 
tended and  tympanitic.  A  rather  hard  mass  is  felt  in  the  right  side  of  the 
abdomen  opposite,  and  a  little  below,  the  umbilicus ;  slightly  movable,  but 
does  not  move  with  respirations.  Her  right  kidney  is  movable.  There  is 
dullness  upon  percussion,  with  the  exception  of  a  small  area  over  the  most 
prominent  part  of  the  abdomen.  The  area  of  dullness  changes  with  a 
change  in  her  position.  Upon  vaginal  examination  the  uterus  is  found 
bound  down  by  a  solid  mass  in  the  pelvis. 

This  history,  together  with  the  physical  examination,  would  indicate  the 
presence  of  a  tubercular  peritonitis  with  fluid  in  the  free  peritoneal  cavity. 
The  fact  that  the  heart,  liver  and  kidneys  are  normal  would  indicate  that 
the  fluid  contained  in  the  peritoneal  cavity  must  be  the  result  of  a  local  irrita- 
tion. This  might  be  due  to  the  presence  of  a  papilloma  originating  from 
the  ovary,  but  that  would  scarcely  account  for  the  mass  in  the  upper  portion 
of  the  peritoneal  cavity,  which  is  probably  the  result  of  adhesions  between 
the  omentum  and  the  intestines,  due  to  abdominal  peritonitis.  It  is  not  dif- 
ficult in  this  case  to  differentiate  betwen  this  condition  and  the  presence  of 
an  ovarian  cyst,  because  the  abdominal  cavity  is  not  so  thoroughly  distended 
as  to  make  all  portions  dull  upon  percussion,  nor  are  the  small  intestines  so 
completely  agglutinated  by  tubercular  peritonitis  as  to  be  held  away  from 
the  circumscribed  accumulation  of  ascitic  fluid,  making  a  resonant  area 
above  or  to  the  side.  The  tubercular  family  history  would  make  a  tubercu- 
lar infection  especially  likely,  although  many  of  these  cases  obtain  their  in- 
fection from  food.  Most  of  these  patients  have  at  least  a  little  elevation  of 
temperature  in  the  afternoon  or  evening,  or  a  subnormal  temperature  in  the 
morning,  and  if  careful  record  of  this  patient's  temperature  had  been  taken 
throughout  her  period  of  sickness,  we  are  confident  that  this  condition  would 
have  been  found  at  some  time.  Even  at  the  present  such  a  variation  in  tem- 
perature could  undoubtedly  be  established  within  a  week  or  two  by  taking 
the  temperature  regularly. 

The  diagnosis  can  be  confirmed  by  using  the  tuberculin  test  or  by  apply- 
ing the  test  introduced  by  Von  Pirquet,  but  in  cases  as  clear  as  this  one 
these  additional  tests  are  not  necessary.  The  latter  is  absolutely  harmless, 
hence  there  is  no  reason  why  it  should  not  be  used  in  every  instance.  The 
tuberculin  test  when  cautiously  applied  so  rarely  does  harm  that  in  the 
event  of  doubt,  it  is  always  well  to  employ  it,  as  it  is  somewhat  more  re- 
liable than  the  other. 

Treatment. 

This  patient  has  been  under  constant  treatment  during  the  past  four 
months  by  a  careful  and  competent  physician.  The  treatment  consisted  of 
hygienic  measures,  of  rest  in  bed,  of  intestinal  antiseptics,  and  she  has  been 
given  good,  wholesome  food,  care  being  exercised  that  the  milk,  and  all  the 
other  food  which  might  possibly  contain  tubercle  bacilli,  was  carefully  steril- 
ized before  use. 

An  incision  three  inches  in  length  is  made  in  the  linea  alba  below  the 
umbilicus.  This  at  once  permits  a  large  quantity  of  thin,  slightly-yellowish 
fluid  to  escape,  leaving  the  peritoneal  cavity  studded  with  tubercles  through- 


GENERAL    SURGERY    OF    THE    ABDOMEN  319 

out,  the  intestines  and  omentum  being  somewhat  adherent  in  the  upper  por- 
tion of  the  peritoneal  cavity ;  the  cecum  and  appendix  to  the  right  being 
covered  with  the  same  small  tubercles,  the  uterus,  ovaries  and  tubes,  and  the 
sigmoid  flexure,  forming  a  mass  in  the  pelvis  also  covered  with  tubercles. 
The  peritoneum  is  one-eighth  of  an  inch  in  thickness,  somewhat  purplish  in 
color  and  completely  studded  with  tubercles. 

After  carefully  sponging  away  all  of  the  free  fluid  with  moist  aseptic 
gauze  pads,  exercising  great  care  not  to  cause  any  abrasions  by  the  manipu- 
lations, a  large  glass  drainage  tube  covered  with  four  thicknesses  of  formidin 
gauze  is  placed  into  the  cul  de  sac  and  permitted  to  project  through  the 
lower  angle  of  the  wound,  then  the  abdominal  wound  is  closed. 

It  is  doubtful  whether,  in  a  patient  like  this  it  is  better  to  close  the  ab- 
dominal cavity  at  once  or  to  insert  a  drainage  tube  surrounded  with  iodo- 
form  gauze,  as  previously  described.  In  case  the  latter  method  is  chosen  the 
tube  and  gauze  should  be  removed  as  soon  as  the  drainage  has  ceased. 

In  following  the  experience  of  a  number  of  surgeons  who  invariably 
drain  these  cases,  and  others  who  close  the  abdominal  cavity  without  drain- 
age, it  has  seemed  that  the  former  have  much  fewer  recurrences  than  the 
latter.  This  has  also  been  our  personal  experience,  so  that  we  now  drain 
invariably  in  all  cases  in  which  we  operate  for  the  relief  of  tuberculous 
peritonitis. 

Medical  vs.  Surgical  Treatment. 

At  the  present  moment  the  treatment  of  tubercular  peritonitis  seems  to 
drift  back  into  the  hands  of  the  practitioner  of  internal  medicine,  after  hav- 
ing been  virtually  considered  a  surgical  disease.  Until  very  recently,  and  for 
a  period  of  more  than  ten  years,  surgeons  were  generally  willing  to  under- 
take the  surgical  treatment,  and  their  immediate  results  were  usually  so  fa- 
vorable that  it  seemed  as  though  the  surgical  treatment  had  become  perma- 
nently established.  Recent  literature,  however,  indicates  that  surgeons  with 
a  considerable  experience  report  approximately  fifty  per  cent,  of  recoveries 
extending  over  at  least  two  years.  Those  who  report  fewer  cases  show  a 
larger  percentage  of  recoveries,  but  it  is  scarcely  fair  to  count  these  cases, 
because  it  is  likely  that  in  this  group  a  greater  proportion  of  favorable  than 
unfavorable  instances  are  reported,  i.  c.,  of  all  surgeons  who  have  operated 
upon  only  one  or  two  of  these  cases  those  who  have  been  fortunate  in  their 
results  will  feel  inclined  to  encourage  others,  while  those  who  have  been  un- 
fortunate abandon  the  subject  as  unworthy  of  special  attention. 

Drainage,  irrigation  and  medication  of  the  abdominal  cavity  are  not 
only  considered  useless  by  many  writers  of  great  experience,  but  actually 
undesirable,  and  the  simpler  the  operation  performed  the  better  will  be  the 
result  according  to  these  authorities.  This  idea  is  illustrated  in  many  of  the 
instances  that  were  found  to  suffer  from  tubercular  peritonitis  when  the 
operation  had  been  performed  with  the  expectation  of  removing  an  ovarian 
cyst,  the  fluid  drained  and  the  abdominal  wound  either  drained  or  closed. 
In  many  such  cases  the  condition  appeared  absolutely  hopeless  and  it 
seemed  to  be  foolish  to  do  anything  at  all. 

A  very  large  number  of  similar  cases  have  been  reported  by  different 
authors  and  the  literature  contains  many  interesting  compilations  of  cases 
which  appear  to  show  great  benefit  from  abdominal  section.  During  the  past 
few  years  it  has  been  shown  that  the  results  in  cases  treated  for  tubercular 
peritonitis  in  the  medical  departments  of  many  of  the  great  hospitals  were 


J2O  GENERAL    SURGERY    OF    THE    ABDOMEN 

about  the  same  as  those  in  the  surgical  clinics.  If  these  observations  are  cor- 
rect it  would  appear  as  though  these  patients  should  be  placed  under  medical 
rather  than  surgical  treatment,  because  the  latter  is,  of  course,  connected 
with  a  greater  amount  of  pain  and  a  slight  amount  of  danger  from  the  op- 
eration itself.  That  many  cases  have  recovered  permanently  and  complete- 
ly after  abdominal  section  there  can  be  no  doubt,  because  this  has  been 
positively  proven  by  autopsies  upon  patients  who  died  from  other  causes, 
when  they  were  found  completely  cured,  tuberculosis  having  been  demon- 
strated at  the  operation  and  the  diagnosis  confirmed  microscopically. 

Many  of  these  patients  have  later  been  operated  for  other  conditions 
and  the  peritoneum  has  been  found  so  entirely  free  from  evidences  of  tuber- 
culosis that  it  seemed  impossible  to  imagine  it  to  be  the  same  peritoneum.  We 
have  made  this  observation  in  a  number  of  our  own  patients. 

Although  the  diagnosis  cannot  be  made  so  positively  in  those  treated 
without  operation,  it  seems  clear  that  many  undoubted  cases  have  been 
cured  by  medical  and  hygienic  measures.  Since  the  introduction  of  the  tu- 
berculin and  Von  Pirquet's  tests  a  positive  diagnosis  can  be  made  even  in 
cases  not  operated,  hence  statistics  in  the  future  will,  of  course,  be  more  ac- 
ceptable. 

An  analysis  of  the  various  papers  on  both  sides  of  this  controversy 
shows,  it  seems,  that  the  authors  were  not  discussing  the  same  class  of  pa- 
tients. 

Medical  Treatment   Generally  Instituted  Early. 

The  medical  practitioners  seem  to  deal  with  these  cases  earlier  in  the 
attack,  while  the  condition  is  still  more  or  less  acute ;  on  the  other  hand, 
surgeons  meet  with  the  cases  in  the  chronic  condition  after  those  which  are 
curable  by  medical  treatment  have  been  eliminated.  In  other  words,  the 
medical  treatment  is  virtually  applied  to  all  cases  at  first,  and  if  persisted  in 
will  result  in  approximately  fifty  per  cent,  of  cures,  of  which  about  one- 
half  have  a  recurrence  after  a  number  of  years.  If  the  medical  treatment  in 
the  remaining  fifty  per  cent,  of  cases  is  continued  after  the  time  when  it 
becomes  apparent  that  it  has  no  beneficial  effect,  then  the  chances  are  that 
such  cases  will  go  from  bad  to  worse  until  they  succumb.  If,  however,  sur- 
gical treatment  is  employed  in  these  cases  in  which  medical  treatment  has 
proven  to  be  of  no  benefit,  then  all  of  the  cases  of  this  group  which  recover 
permanently,  as  well  as  those  which  are  temporarily  improved,  constitute  an 
absolute  gain,  because  they  reduce  the  failures  from  the  internal  treatment 
and  increase  the  favorable  results  by  their  entire  number. 

It  is  interesting  to  note  that  all  authors  who  favor  the  medical  treatment 
of  these  cases  insist  upon  beginning  during  the  early  part  of  the  attack,  in 
fact,  as  soon  as  the  diagnosis  has  been  made.  They  all  advise  primarily  hy- 
gienic measures ;  rest  in  bed,  intestinal  antiseptics,  some  form  of  creosote, 
and  some  form  of  iodine  to  be  given  internally ;  also  sterilized,  concentrated 
food  and  living  and  sleeping  in  the  open  air. 

Many  external  applications  have  been  advised,  especially  ointments 
containing  some  form  of  iodine  or  mercury.  Those  advising  surgical  treat- 
ment combine  hygienic  treatment  with  it  and  advise  that  this  be  continued  in- 
definitely after  the  recovery  from  the  operation. 

Of  those  who  advise  operative  treatment  several  surgeons  of  large  ex- 
perience caution  against  operation  too  early  in  the  attack,  because  recur- 
rence is  more  likely  in  case  the  operation  is  performed  before  the  tubercles 


GENERAL    SURGERY    OF    THE    ABDOMEN  321 

are  fully  developed.  It  has  been  demonstrated  experimentally  that  this  is  a 
wise  precaution  to  take,  because  new  tubercles  developed  in  animals  after  an 
early  laparotomy,  while  in  other  similar  animals  a  later  operation  has  resulted 
in  a  permanent  cure.  The  cure  is  attributed  to  the  secretion  of  an  antitoxin 
which,  it  is  claimed,  is  not  produced  before  the  tubercles  have  been  fully  de- 
veloped. 

Many  experiments  have  been  made  to  determine  the  manner  in  which 
the  cure  is  accomplished.  It  has  been  demonstrated  in  animals,  upon  which 
an  artificial  tubercular  peritonitis  had  been  produced,  that  the  abdominal 
section  is  followed  by  a  severe  hyperemia  which  lasts  longer  than  in  cases 
not  suffering  from  tubercular  peritonitis.  This  is  considered  the  curative  ele- 
ment which  is  attributed  to  the  action  of  the  air  upon  the  diseased  perito- 
neum, as  it  does  not  occur  when  the  animals  are  kept  submerged  in  normal 
salt  solution  during  the  operation.  Other  authors  have  attributed  the  cura- 
tive effect  of  abdominal  section  to  an  antitoxin  produced  from  the  dead 
bacilli,  which  will  be  absorbed.  These  conclusions  are  also  based  upon  ex- 
perimental research.  It  has  been  found  that  the  antitoxic  effect  of  the  ascitic 
fluid  increases  with  its  age. 

Resume  of  Cases. 

We  have  had  occasion  to  review  personal  experience  in  the  treatment  of 
tubercular  peritonitis  by  laparotomy.  The  accompanying  table  contains  all 
the  cases  of  tubercular  peritonitis  upon  which  abdominal  section  has  been 
done  at  the  Augustana  Hospital  during  the  past  few  years,  with  the  hope  of 
obtaining  a  permanent  cure.  This  group  (see  following  table)  contains 
thirty-two  cases,  varying  in  age  from  nine  to  fifty-six  years.  Since  con- 
structing this  table  a  few  years  ago,  we  have  treated  a  considerable  number 
of  patients  suffering  from  tubercular  peritonitis  whose  outcome  serves  to 
still  further  confirm  the  views  we  have  expressed  upon  this  subject.  (We 
now  have  operated  upon  more  than  three  times  this  number  of  cases,  but  it 
does  not  seem  proper  to  take  up  the  space  necessary  to  tabulate  all  of  these 
because  they  show  that  our  views  expressed  a  few  years  ago  must  be  consid- 
ered correct,  although  the  additional  vaccine  treatment  has  still  further  im- 
proved both  the  surgical  and  the  non-surgical  result.  The  use  of  out-of- 
door  sleeping  apartments  has  also  been  of  great  benefit  in  the  treatment  of 
these  cases). 

From  the  age  of     8  to  19  there  were  n  cases. 

From  the  age  of  19  to  29  there  were     9  cases. 

From  the  age  of  29  to  39  there  were     6  cases. 

From  the  age  of  39  to  49  there  were  3  cases. 

Above  the  age  of  49  there  were  3  cases  (55,  56,  58  years  of  age). 

There  were  twenty-four  female  and  eight  male  patients. 

But  one  patient  died  as  a  direct  result  of  the  operation,  on  the  seventh 
day,  from  exhaustion.  The  appendix  in  this  case  was  tuberculous  and  was 
deeply  imbedded  between  the  cecum,  the  ileum  and  the  omentum.  Its  re- 
moval necessitated  a  very  tedious  dissection.  It  seemed  at  that  time  that  it 
would  not  be  good  surgery  to  leave  this  infected  organ  in  the  abdominal 
cavity.  The  patient  was  fifty-five  years  of  age  and  her  resistance  was  not 
good.  She  never  reacted  from  the  operation.  We  are  now  positive  that 
this  was  bad  surgery,  because  in  other  similar  cases  in  which  we  simply  re- 
moved the  fluid,  exposed  the  peritoneum  to  the  air  and  closed  the  abdominal 


322  GENERAL    SURGERY    OF    THE    ABDOMEN 

wall,  draining  the  cavity  for  a  week  or  longer,  the  patients  have  usually  done 
surprisingly  well. 

In  this  series  (see  table)  there  were  several  such  (Nos.  2,  8,  10,  15,  16, 
18,  19,  23,  27,  30,  31,  32)  in  a  similar  and,  in  fact,  most  of  them  in  a  worse 
condition.  Several  were  so  advanced  that  nothing  was  done  after  the  abdo- 
men was  opened  except  to  empty  the  fluid,  because  it  seemed  absolutely  use- 
less, the  cases  being  apparently  in  a  hopeless  condition.  Nevertheless  they 
recovered  from  the  operation  and  many  have  been  perfectly  well  for  many 
years,  as  will  be  seen  from  the  table. 

We  were  impressed  most  thoroughly  with  this  fact  by  two  cases,  whose 
histories  will  be  given  in  abstract  to  illustrate  the  extent  to  which  recovery 
may  occur  in  instances  in  which  the  pathological  condition  at  the  time  of  the 
operation  seemed  to  preclude  the  possibility  of  a  complete  recovery.  The 
first  of  these  does  not  belong  to  the  group  in  the  accompanying  table,  be- 
cause she  was  not  operated  in  our  hospital.  We  simply  quote  the  case  be- 
cause it  shows  more  perfectly  the  possibilities  in  these  conditions  than  any 
of  the  cases  in  the  present  group. 

In  June,  1891,  we  operated  upon  a  married  woman,  twenty-six  years  of 
age,  whose  ovaries,  tubes  and  uterus  were  imbedded  in  a  thick  mass  of 
tuberculous  tissue  so  extensive  that  it  seemed  absolutely  useless  to  attempt 
their  removal.  The  cecum,  omentum  and  the  small  intestines  were  also 
matted  together,  a  condition  very  similar  to  that  found  in  Case  31.  The  en- 
tire parietal  and  intestinal  peritoneum  was  thickly  studded  with  tubercles. 
The  remaining  abdominal  space  was  greatly  distended  with  fluid  and  we 
simply  inserted  a  drainage  tube  in  the  hope  of  giving  the  patient  a  slight 
amount  of  temporary  relief  and  closed  the  remaining  portion  of  the  abdom- 
inal wound.  She  recovered  slowly  but  was  able  to  return  to  her  home 
in  six  weeks.  It  is  now  nineteen  years  since  we  performed  this  operation, 
and  the  patient  is  a  strong,  healthy  woman  and  has  given  birth  to  two  healthy 
children.  When  we  inquired  six  years  after  the  operation  of  her  family 
physician  for  the  date  of  death  after  her  return  to  her  home  from  the 
hospital,  we  were  amazed  to  learn  of  the  subsequent  history,  in  part  as 
stated  above. 

Case  No.  8  of  the  group  is  a  similar  example.  This  patient  came  under 
our  care  May  i,  1896,  and  was  operated  on  the  following  day.  She  was  then 
fifteen  years  of  age,  was  reduced  to  a  skeleton,  weighing  but  sixty-two 
pounds.  The  abdomen  was  distended  to  the  size  of  a  five  months'  preg- 
nancy, she  was  compelled  to  sit  with  her  knees  drawn  up  on  her  abdomen 
so  that  she  rested  her  hands  and  her  forearms  upon  them  and  on  these  she 
rested  her  chin.  This  was  the  only  position  in  which  she  could  be  com- 
fortable. We  performed  an  abdominal  section  ;  finding  four  pints  of  free 
fluid.  The  intestines,  omentum,  ovaries  and  tubes  were  so  thoroughly  im- 
bedded in  masses  of  tuberculous  tissue  that  the  case  seemed  hopeless.  A 
drainage  tube  was  inserted.  The  patient  began  to  gain  slowly  but  steadily. 
She  took  anti-tuberculous  remedies  for  several  years  and  developed  into  a 
beautiful,  healthv  woman.  In  a  letter  we  received  a  few  days  ago,  she  states 
that  her  health  is  perfect,  that  she  now  weighs  one  hundred  and  twenty 
pounds — which  is  more  than  double  her  weight  at  the  time  of  the  operation 
after  the  ascitic  fluid  had  been  removed.  Her  photograph,  which  she  sent, 
shows  her  to  be  vigorous,  well-nourished,  beautiful,  and  evidently  completely 
recovered  from  her  tuberculous  disease. 

Of  the  patients  who  died  a  short  time  after  the  operation,  but  not  di- 


GENERAL    SURGERY    OF    THE    ABDOMEN 


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326  GENERAL    SURGERY    OF    THE    ABDOMEN 

rectly  as  a  result  thereof,  it  seerns  important  to  observe  that  in  Case  14  the 
condition  was  complicated  by  tertiary  syphilis,  the  abdominal  ascites,  due  to 
the  tubercular  peritonitis,  increased  constantly  and  the  patient's  condition  be- 
came more  serious  under  the  anti-syphilitic  treatment  which  had  been  insti- 
tuted previous  to  the  operation.  It  seemed  as  though  the  patient  could  be 
more  readily  relieved  of  the  syphilis  after  being  relieved  of  the  ascites,  but 
the  result  was  quite  the  reverse.  It  is  possible  that  the  operation  hastened 
her  death,  althqugh  she  was  rapidly  approaching  a  fatal  conclusion  when  the 
operation  was  performed. 

In  a  similar  case  since  the  above  we  have  treated  the  syphilis  by  placing 
the  patient's  body  in  a  tent  placed  over  her  bed  with  the  head  projecting 
through  an  opening  which  fitted  tightly  about  the  neck  after  the  manner  of 
a  hot-air  cabinet,  then  we  filled  this  tent  with  hot  air  generated  by  a  Bunsen 
gas  burner.  After  the  patient  had  began  to  perspire  freely  an  iron  dish  con- 
taining one  hundred  and  twenty  grains  of  calomel  was  placed  over  the  flame, 
causing  the  calomel  to  evaporate,  and  fall  upon  the  patient's  moist  skin.  This 
treatment  was  repeated  once  daily  for  one  month  when  the  evidences  of  the 
syphilis  had  disappeared.  Of  course  the  necessary  precautions  were  ob- 
served to  prevent  salivation.  The  teeth  were  carefully  cleansed  and  abso- 
lutely nothing,  containing  acids  was  given  by  mouth.  A  saline  laxative  was 
administered  every  morning  and  the  nutrition  and  general  hygiene  of  the 
patient  were  carefully  controlled.  After  removing  the  syphilis  in  this  manner, 
which  did  not  interfere  with  her  nutrition  but  rapidly  increased  her  strength 
and  inproved  her  general  health,  she  made  a  normal  recovery  from  her 
tuberculous  peritonitis. 

This  method  is  mentioned  because  in  many  cases  in  which  syphilis  does 
not  yield  to  the  administration  of  mercury  by  mouth  or  by  inunctions  or  by 
intramuscular  injection,  in  weak  patients  the  disease  yields  at  once  upon 
instituting  this  form  of  medication. 

Case  21  improved  rapidly  after  the  operation  and  was  able  to  return 
to  her  home  after  one  month,  but  succumbed  to  a  new  invasion  three  months 
later.  It  is  not  likely  that  the  diffuse,  miliary  tuberculosis  of  which  she  died 
had  any  relation  to  her  operation. 

Case  22  was  complicated  with  the  comparatively  rare  condition  of 
tuberculosis  of  the  pancreas.  The  patient  was  more  comfortable  after  the 
operation,  but  it  is  not  likely  that  the  procedure  either  lengthened  or  short- 
ened her  life. 

In  Case  27  a  latent  pulmonary  tuberculosis  became  very  active  directly 
after  the  operation.  It  is  probable  that  he  would  have  lived  a  little  longer 
without  the  operation.  It  has  been  observed  that  patients  with  a  tubercular 
family  history,  suffering  from  even  a  slight  pulmonary  tuberculosis  com- 
plicating the  tubercular  peritonitis,  do  not  recover  readily  from  the  latter 
condition  after  abdominal  section.  In  this  class  of  patients  living  and 
sleeping  out  of  doors  and  careful  feeding  and  non-irritating  intestinal  anti- 
septics undoubtedly  should  be  employed  most  carefully  before  an  operation 
is  undertaken. 

In  twenty-one  out  of  thirty-two  of  the  patients  in  this  series  we  have 
obtained  definite  information  concerning  their  history  after  leaving  the  hos- 
pital. Of  these  cases  fifteen  were  well  from  one  to  eleven  years  after  the 
operation,  five  had  died,  two  are  too  recent  to  be  considered  except  from  the 
standpoint  of  immediate  recovery  from  the  operation.  Ten  cases  we  have 


GENERAL    SURGERY    OF    THE    ABDOMEN  327 

not  been  able  to  trace ;  they  belong  to  the  laboring  classes  who  have  no 
permanent  homes. 

All  of  these  patients  had  been  under  internal  treatment  for  a  consider- 
able period  of  time  before  the  .abdominal  section  was  performed,  without 
being  benefited ;  several  of  those  who  have  apparently  made  a  permanent 
recovery  were  in  what  seemed  to  be  an  entirely  hopeless  condition  when  they 
entered  the  hospital. 

A  study  of  the  literature,  together  with  a  review  of  our  clinical  experi- 
ence with  the  cases  contained  in  the  accompanying  table,  and  with  those  that 
have  been  under  observation  since  this  table  was  compiled,  seems  to  warrant 
the  following  conclusions : 

Conclusions. 

i  st.  Patients  suffering  from  tubercular  peritonitis  should  first  be  sub- 
jected to  careful  medical,  dietetic  and  hygienic  treatment. 

2nd.  This  treatment  should  consist  in  the  use  of  intestinal  antiseptics, 
anti-tubercular  remedies  and  rest  in  bed.  Sterilized  food  and  improved 
hygienic  conditions  generally  should  be  employed.  The  vaccine  treatment 
should  be  carefully  tried  in  these  cases. 

3rd.  So  long  as  the  patient's  condition  improves  reasonably  this  treat- 
ment should  be  continued. 

4th.  In  case  the  patient's  condition  does  not  improve,  or  becomes  worse, 
abdominal  section  is  indicated. 

5th.  If  the  disease  is  confined  to  a  part  which  can  be  safely  removed 
without  injuring  any  portion  of  the  tuberculous  peritoneum  this  should  be 
done,  provided  the  surface  can  be  covered  with  healthy  peritoneum. 

6th.  If  the  removal  of  any  infected  portion  necessitates  the  severing  of 
the  tuberculous  peritoneum  or  leaving  a  portion  of  the  peritoneal  surface 
denuded,  the  diseased  tissue  must  not  be  disturbed. 

7th.  In  case  there  is  fluid  in  the  peritoneal  cavity  it  is  doubtful  whether 
it  is  best  to  remove  any  tuberculous  tissue,  even  though  it  be  circumscribed. 

8th.  Enormous  quantities  of  the  tuberculous  material  can  be  absorbed 
from  the  peritoneal  cavity  after  simple  laparotomy. 

9th.  It  is  best  to  avoid  all  manipulation  of  the  intra-abdominal  organs 
during  the  operation,  in  case  there  is  a  diffuse  tuberculous  infection,  and  to 
confine  the  operation  to  simply  opening  the  peritoneal  cavity,  permitting  the 
fluid  to  drain  out,  admitting  air  to  the  peritoneal  cavity,  draining  the  cavity 
with  a  glass  tube  covered  with  gauze  and  closing  the  abdominal  wound. 

loth.  Peritoneal  adhesions  should  never  be  disturbed  in  patients  suf- 
fering from  tubercular  peritonitis  with  ascites  for  fear  of  causing  intestinal 
fistulae. 

nth.  During  the  time  of  recovery  from  the  surgical  operation,  and  for 
a  considerable  period  of  time  after  this,  the  patient  should  be  treated 
medically. 

1 2th.  The  hygienic  conditions  of  the  patient  must  be  permanently  im- 
proved and  he  must  not  be  permitted  to  expose  himself  to  the  influences 
which  primarily  caused  the  tuberculous  infection. 

I3th.  Permanency  of  cure  is  much  more  likely  in  patients  who  are 
not  predisposed  to  pulmonary  tuberculosis. 

1 4th.  Chronic  cases  with  fluid,  particularly  if  encapsulated,  and  not 
benefited  by  medical  and  hygienic  measures,  are  especially  amenable  to 
surgical  treatment. 


328  GENERAL    SURGERY    OF    THE    ABDOMEN 

1 5th.  Repeated  operations  are  indicated  in  case  of  re-accumulation  of 
fluid. 

1 6th.  It  is  important  to  regulate  the  hygiene  and  diet  of  these  patients 
permanently  after  they  have  recovered  from  this  disease. 

1 7th.  It  is  especially  important  to  locate  the  source  of  the  primary  in- 
fection and  to  make  reinfection  from  this  source  impossible. 

1 8th.  If  possible  they  should  change  their  residence  sufficiently  to 
insure  satisfactory  hygienic  conditions. 

1 9th.  All  milk  and  all  meats  should  be  sufficiently  cooked  to  prevent 
reinfection  from  these  sources. 

20.  In  employing  the  vaccine  treatment  it  is  of  the  greatest  importance 
to  use  a  very  small  dosage,  a  good  rule  being  to  administer  one-half  of  the 
smallest  dose  that  will  cause  the  slightest  reaction. 

GENERAL  CONSIDERATIONS  IN  BOWEL  SURGERY. 

The  greatest  number  of  operations  upon  the  intestines  are  performed 
for  the  relief  of  mechanical  obstruction.  This  may  be  due  to  strangulation, 
as  in  strangulated  hernia,  or  constriction  due  to  a  cicatricial  band  or  an 
adherent  MeckePs  diverticulum,  or  an  adherent  appendix  or  a  volvulus. 
Again  operation  may  be  needful  for  the  relief  of  obstruction  due  to  a 
foreign  body  in  the  alimentary  canal,  such  as  a  gall  stone  or  an  enterolith, 
or  to  a  malignant  growth  occluding  the  lumen  of  the  intestine  or  to  an 
intussusception. 

General  Principles  in  Bowel  Surgery. 

There  are  a  few  general  principles  which  should  be  borne  in  mind  in  all 
surgical  work  upon  the  intestine,  viz. 

1.  The   circulation   should  be  as  perfect  as  possible   at  the  point  of 
operation.     There   is   always   great   danger   of   interfering   with   the   blood 
supply  when  sutures  or  ligatures  are  applied  in  the  vicinity  of  the  omentum 
or  the  mesentery. 

2.  Care  should  be  taken  never  to  apply   stitches  or  ligatures  to  the 
omentum    near    its    attachment    to    the    colon,    because    this    is    .frequently 
followed  by  gangrene. 

3.  In  all  operations  it  is  important  to  apply  the  sutures  so  that  the 
two  layers  of  the  mesentery  are  held  together,  because  the  space  between 
these  layers  is  not  covered  with  peritoneum  and  is  consequently  deprived  of 
nutrition  if  this  precaution  be  not  taken.    When  an  end-to-end  anastomosis 
is  made   in   the   small   intestine   this   danger   can   be   still    further   guarded 
against  by  placing  the  ends  so  that  the  mesentery  does  not  come  directly 
in  apposition  in  the  two  segments,  twisting  one  segment  a  few  degrees  to 
the  right  and  the  other  a  few  degrees  to  the  left,  so  that  there  is  a  distance 
of    about   one-eighth    of   the   circumference    of    the    intestine    between    the 
mesenteric  attachments  of  the  two  segments. 

4.  The  same  principle  applies  to  the  choice  of  location  and  form  of  the 
anastomosis.     It  is  always  safer  to  make  an  anastomosis  where  it  is  possible 
to  unite  surfaces  which  are  covered   with  peritoneum,  hence  in  many   in- 
stances a  side-to-sicle,  or  an  end-to-side  anastomosis  is  to  be  preferred  to 
an  end-to-end  junction. 

5.  Tension  should  always  be  avoided. 

6.  The  omentum  can  be  utilized  to  enforce  an  anastomosis  by  sup- 
plying nutrition  from  its  rich  circulation. 


GENERAL    SURGERY    OF    THE    ABDOMEN 

7.  When  an  anastomosis  or    enterorrhaphy  is    performed    after  re- 
moving- a  portion  of  gangrenous  intestine  the  proximal  segment  is  likely  to 
cause   leakage   unless   the  enterorrhaphy   is   made  a   considerable   distance 
above  the  portion  of  intestine  that  was  gangrenous. 

8.  In  case  of  tumors  of  the  mesentery  it  is  wise  to  make  an  anastom- 
osis which  will  permit  the  passage  of  intestinal  contents  above  the  point  at 
which  the  nutrition  has  been   impaired  by  the   removal   of  a  mesenteric 
tumor. 

9.  Care  must  be  taken  to  prevent  angulation,  which  will  result  later  in 
obstruction. 

10.  Allowance  must  be  made  for  shrinkage  of  the  anastomosis  open- 
ings, due  to  cicatricial  constriction. 

11.  Care  must  be  used  to  prevent  free  spaces  underneath  intestines 
through  which  herniae  may  occur  later. 

12.  Raw  surfaces  should  never  be  left  in  intestinal  operations  because 
adhesions  are  especially  bad  in  these  cases. 

EXCISION  OF  THE  CECUM. 
Typical  History. 

The  patient  is  a  farmer  fifty-six  years  of  age  who  gives  the  following 
history:  Family  and  previous  history  negative.  Has  enjoyed  good  health 
and  has  been  able  to  work  hard  until  a  few  months  ago.  The  only  discomfort 
he  has  experienced  has  been  from  chronic  constipation  which  has  existed  for 
many  years,  but  which  has  alternated  during  the  past  year  with  acute 
attacks  of  "dysentery"  which  have  lasted  but  a  day  or  two  at  a  time.  He  has 
suffered  from  indigestion  and  from  gaseous  distension  of  the  abdomen. 
The  latter  condition  has  become  worse  constantly  during  the  past  few 
months.  In  the  meantime  the  patient  has  lost  forty  pounds  in  weight,  his 
appetite  having  constantly  become  more  and  more  impaired,  and  during 
the  past  few  weeks  he  has  frequently  experienced  a  feeling  of  nausea. 

He  is  a  somewhat  emaciated,  slightly  cachectic  man,  skin  dry,  very 
slightly  jaundiced,  tongue  coated,  appetite  poor,  severely  constipated,  heart, 
lungs  and  kidneys  normal,  temperature  slightly  sub-normal.  Abdomen  thin- 
walled,  soft,  slightly  distended,  peristalsis  of  small  intestines  can  be  seen 
on  surface  of  the  abdomen.  At  a  point  half-way  between  the  end  of  the 
twelfth  rib  and  the  anterior  superior  spine  of  the  ilium  a  hard,  oval,  slightly 
lobulated  mass  apparently  four  inches  in  length  and  two  inches  in  diameter 
can  be  felt  through  the  abdominal  wall.  It  is  slightly  movable  and  not 
especially  painful  upon  manipulation.  It  seems  to  be  attached  posteriorly. 
Upon  inflation  of  the  colon  by  means  of  a  bicycle  pump  attached  to  a  rectal 
tube  the  tumor  is  not  displaced  and  the  gas  does  not  distend  the  colon  in 
front  of  it.  The  distension  seems  to  extend  to  a  point  directly  above  the 
beginning  of  the  tumor. 

Diagnosis. 

A  careful  review  of  this  history  must  direct  our  attention  to  the  exist- 
ence of  partial  obstruction  of  the  alimentary  canal,  which  is  increasing  in 
character  and  has  of  late  become  almost  complete,  as  indicated  by  the 
frequent  feeling  of  nausea. 

The  location  of  the  tumor  corresponds  to  the  cecum  or  the  ascending 
colon.  Its  sessile  nature  would  indicate  the  same  organ.  The  fact  that  it  is 


33°  GENERAL    SURGERY    OF    THE    ABDOMEN 

not  disturbed  by  the  inflation  of  the  colon  would  eliminate  the  kidney  and 
the  gall  bladder.  The  fact  that  continued  treatment  with  cathartics  does  not 
affect  the  size  or  form  of  this  tumor,  wquld  eliminate  fecal  impaction.  The 
age  of  the  patient  and  the  cachexia  would  point  toward  malignancy.  We  will 
consequently  make  a  diagnosis  of  carcinoma  of  the  cecum  or  the  ascending 
colon,  or  both. 

Indications  for  Treatment. 

There  has  been  a  constant  increase  in  the  obstruction,  hence  it  is  to  be 
expected  that  a  complete  interference  must  occur  soon.  In  order  to  avoid 
this  some  radical  measure  must  be  instituted.  Moreover,  this  should  be 
undertaken  before  the  patient's  strength  has  declined  still  more.  We  shall 
consequently  advise  an  operation  as  soon  as  the  patient  has  received  the 
necessary  preparation. 

Complete  intestinal  obstruction  might  occur  in  this  case  at  any  time  by 
the  occlusion  of  the  slight  remaining  opening  in  this  intestine  with  some 
small  mass  of  undigested  food.  A  small  piece  of  meat  fiber  or  an  orange 
seed,  and  in  a  number  of  cases  an  enterolith,  has  been  observed  to  cause  a 
complete  obstruction.  In  case  this  occurs  the  condition  becomes  exceedingly 
grave  at  once,  because  the  same  symptoms  will  arise  which  characterize 
acute  mechanical  obstruction  of  the  intestine,  namely,  pain,  sudden  gaseous 
distension  of  the  abdomen,  nausea,  vomiting  and  shock.  Patients  quite  ad- 
vanced in  age  and  greatly  reduced  by  long-continued  disease  do  not  bear 
this  condition  well. 

The  Question  of  an  Immediate  Operation. 

The  question  consequently  arises  as  to  the  advisability  of  an  immediate 
operation  when  a  complete  obstruction  has  occurred.  Should  the  patient 
come  under  treatment  at  once  the  immediate  operation  is  undoubtedly  in- 
dicated, because  the  intestines  are  still  in  a  good  condition  and  the  patient  has 
not  lost  much  strength.  It  has,  however,  been  our  experience  that  these 
patients  have  become  accustomed  to  the  use  of  strong  cathartics  and  that 
consequently  they  are  likely  to  employ  such  means  for  several  clays  before 
consulting  a  physician,  changing  from  one  to  the  other  drug  until  they  are 
completely  exhausted.  In  such  examples  we  have  found  that  an  immediate 
operation  is  usually  followed  by  the  speedy  death  of  the  patient,  because 
his  strength  has  been  greatly  impaired  and  great  pressure  has  been  brought 
to  bear  upon  the  badly  nourished  intestinal  walls  above  the  point  of  ob- 
struction from  the  constant  use  of  strong  cathartics.  The  intestines  are 
distended,  making  an  operation  extremely  tedious.  This  distension  is  ac- 
companied by  a  greater  permeability  of  the  walls  to  the  passage  of  micro- 
organisms, hence  an  infection  is  favored  in  this  manner.  It  usually  becomes 
necessarv  to  open  the  intestine  and  to  permit  its  contents  to  escape  before 
the  bowels  can  be  replaced  in  the  abdominal  cavity.  This  evacuation  should 
be  accomplished  through  a  large  glass  tube,  to  be  described  presently, 
through  which  the  intestine  should  be  thoroughly  irrigated  with  normal  salt 
solution  at  105°  to  110°  F.  The  administration  of  cathartics  after  complete 
obstruction  has  occurred  accounts  for  the  extremely  high  death  rate  in 
cases  operated  upon  under  these  conditions. 

For  a  number  of  years  we  have  consequently  followed  another  plan  and 
have  found  it  far  safer  for  the  patient.  Many  cases  brought  to  the  hospital 
in  an  apparently  hopeless  state  have  improved  from  day  to  day  and  were 


PLATE  XXXII. 

INTESTINAL  ANASTOMOSIS. 

End  to  end  with  Murphy  button:  (a)  button  in  place  with  purse-string  suture 
tied;  (b)  end  of  intestine  with  suture  in  place,  showing  manner  of  including  mesen- 
tery at  (d)  :  a  mesenteric  vessel  is  represented  as  tied  at  a  point  a  little  below  and 
to  the  left  of  (d)  :  (c)  represents  the  remaining  half  of  the  button  to  be  introduced 
into  the  segment  (b). 


GENERAL    SURGERY    OF    THE    ABDOMEN  333 

presently  carried  to  a  point  at  which  it  was  possible  to  perform  the  necessary 
operation  safely.  Of  course  there  are  cases  which  are  moribund  at  the  time 
of  admission  to  the  hospital  and  these  will  die,  usually  within  a  few  hours 
after  admission,  no  matter  whether  or  not  they  are  operated. 

Conservative  Treatment. 

The  treatment  that  has  been  followed  by  the  greatest  percentage  of 
recoveries  in  our  experience  has  consisted  in  reducing  the  pressure,  as  much 
as  possible,  above  the  point  of  constriction.  This  can  be  accomplished  best  by 
performing  gastric  lavage  several  times,  at  intervals  of  a  few  hours,  under 
cocain  anesthesia  of  the  pharynx.  There  is  usually  a  regurgitation  of  decom- 
posing material  into  the  stomach,  which  will  be  removed  by  the  gastric 
lavage.  In  this  manner  the  stomach,  and  the  intestine  above  the  obstruction, 
soon  become  emptied  of  decomposing  material  and  gas.  The  distension  dis- 
appears gradually,  the  intestinal  walls  seem  to  regain  their  power  of  con- 
traction, the  absorption  of  products  of  decomposition  ceases  and  the  patient's 
condition  improves  practically  in  all  cases  in  which  the  intestines  still  contain 
a  sufficient  amount  of  tone  to  force  their  contents  back  into  the  stomach  by 
return  peristalsis. 

The  emptying  of  the  intestines  above  the  point  of  obstruction  can  be 
further  facilitated  by  elevating  the  foot  of  the  bed,  which  favors  the  flow 
of  intestinal  contents  back  into  the  stomach  where  the  accumulation  will  be 
indicated  by  the  presence  of  nausea,  which  is  again  relieved  by  gastric 
lavage.  This  precaution  is  of  importance  moreover  because  it  will  protect 
the  patient  against  drowning  in  his  own  vomit,  an  accident  which  we  have 
observed  several  times. 

In  case  the  obstruction  is  due  to  the  wedging  of  a  fine  substance  into  a 
constriction  caused  by  the  presence  of  a  carcinoma  in  the  colon  the  method 
named  of  relieving  the  pressure  from  above  may  result  in  its  dislodgment. 
Maury  has  shown  that  patients  with  intestinal  obstruction  are  severely 
poisoned  by  a  secretion  from  the  mucous  lining  of  the  duodenum,  which 
explains  why  many  of  them  recover  so  splendidly  after  repeated  gastric 
lavages,  because  this  poisonous  substance  is  regurgitated  into  the  stomach 
and  washed  away  by  the  lavage. 

In  the  meantime  the  patient  is  supported  by  the  use  of  nutrient  enemata, 
one  ounce  of  liquid  predigested  food  being  dissolved  in  three  ounces  of 
normal  salt  solution  and  administered  through  a  soft  catheter  mserted  into 
the  rectum  a  distance  of  about  two  inches.  This  should  be  repeated  once  in 
four  hours.  If  the  patient  suffers  from  thirst  half  a  pint  of  normal  salt 
solution  may  be  given  as  an  enema  in  the  same  manner  every  hour  until  the 
thirst  has  subsided.  It  is  important  not  to  introduce  the  catheter  a  greater 
distance  than  about  two  inches  because  otherwise  one  frequently  observes 
severe  irritation. 

This  treatment  can  usually  be  continued  with  benefit  and  with  safety  for 
a  number  of  weeks.  In  many  cases  the  absence  of  irritation  and  pressure 
from  above  will  result  in  the  passage  of  gas  and  liquid  feces  through  ,the 
stricture,  because  there  is  always  a  certain  amount  of  edema  which  subsides 
when  the  irritation  has  disappeared. 

It  is  best  not  to  give  any  food  by  mouth  in  these  patients,  after  the 
obstruction  has  once  been  complete,  until  the  hindrance  has  been  removed. 
Should  it  seem  necessary  to  postpone  the  operation  for  a  time  it  is  best  to 
continue  the  use  of  the  nutrient  enemata  and  to  give  only  such  nourishment 


334  GENERAL    SURGERY    OF    THE    ABDOMEN 

by  mouth  as  will  be  completely  absorbed  from  the  stomach  and  small  in- 
testines. 

After  this  condition  of  relief  has  been  attained  in  cases  of  complete 
intestinal  obstruction  due  to  the  presence  of  carcinoma  in  the  colon,  the 
treatment  will  be  the  same  as  in  those  in  which  the  obstruction  is  not 
complete.  In  cases  in  which  the  stricture  remains  impermeable,  the  operation 
for  the  relief  of  the  obstruction  will  have  to  be  carried  out  at  a  time  which 
seems  favorable  in  the  judgment  of  the  surgeon  who  has  the  case  under 
observation.  In  these  cases  there  can,  of  course,  be  no  further  preparatory 
treatment. 
Preparatory  Treatment. 

In  all  operations  upon  the  alimentary  canal  it  is  well  first  to  remove  so 
far  as  possible  all  of  the  contents  thereof  by  the  administration  of  cathartics 
and  large  enemata  and  then  keeping  the  patient  on  sterilized  food  entirely 
until  the  time  of  the  operation.  It  is  well  to  repeat  the  cathartics  once  or 
twice,  if  the  patient's  condition  warrants  it,  in  order  to  remove  as  much 
as  possible  all  infectious  material  from  the  alimentary  canal.  Two  ounces 
of  castor  oil,  given  in  the  foam  of  beer,  ale  or  malt  extract,  is  usually  most 
effective  and  gives  rise  to  the  least  amount  of  irritation. 

Especial  stress  should  be  laid  upon  the  value  of  castor  oil  used  in  the 
manner  indicated  above.  From  time  to  time  we  have  tried  other  cathartics 
but  have  become  absolutely  convinced  of  the  fact  that  none  of  them  serve 
the  purpose  of  removing  septic  material  from  the  alimentary  canal  so  per- 
fectly as  this  remedy  when  given  in  this  dose  and  vehicle.  It  is  tasteless, 
non-irritating,  rarely  produces  nausea  or  vomiting  and  the  results  are  ideal. 

In  cases  in  which  there  is  but  a  small  opening  left,  but  which  is  still 
permeable  we  often  give  two  ounces  of  castor  oil  once  or  twice  daily  for 
several  clays  before  the  operation,  and  follow  this  by  the  administration  of 
large  normal  salt  solution  flushings  of  the  lower  bowel.  This  clears  up  the 
patient's  general  appearance  greatly,  as  they  have  usually  absorbed  fecal 
material  lodged  above  the  seat  of  obstruction  for  months  before  they  come 
under  our  care.  Of  course  it  is  of  importance  in  the  meantime  not  to  give 
food  which  will  favor  further  accumulation. 

The  patient  may  chew  tender  broiled  steak  and  swallow  the  juice  but  not 
the  pulp,  or  take  egg  albumen,  broth,  fruit  juices  and  milk  with  lime  water 
or  with  milk  of  magnesia. 

The  field  of  operation  is  prepared  in  the  usual  way. 

Technique  of  Operation. 

In  this  patient  the  tumor  can  be  located  definitely,  consequently  the 
incision  will  be  made  in  a  position  facilitating  its  removal.  It  is  not  possible 
to  determine  the  exact  length  of  incision  that  may  be  required  for  the 
removal  of  this  tumor,  hence  we  must  choose  a  location  for  the  incision 
which  will  permit  of  its  enlargement.  We  will  choose  the  outer  edge  of  the 
right  rectus  abdominis  muscle,  as  shown  in  Plate  XIV  c.  This  may  be 
lengthened  indefinitely  if  it  should  seem  desirable  during  the  process  of  the 
operation. 

We  find  a  tumor  in  the  cecum  and  ascending  colon  beginning  a  little 
above  the  entrance  of  the  ileum  into  the  cecum.  The  tumor  is  about  twelve 
cm.  in  length  and  involves  the  entire  circumference  of  the  intestine.  It  is 
exceedingly  hard,  but  apparently  has  not  perforated  the  wall  of  the  bowel 
at  any  point.  It  seems  as  though  the  entire  growth  were  still  confined  to 


X 


PLATE  XXXIII. 

LATERAL  ANASTOMOSIS   OF   INTESTINES   WITH    MURPHY   BUTTON. 

This  plate  does  not  show  the  end  of  the  intestine  properly;  the  tissue  should 
be  represented  as  inverted  into  the  lumen  of  the  intestine  by  means  of  Lembert 
sutures  at  (d)  and  (e).  At  (a)  the  purse-string  suture  is  represented  as  applied 
properly,  with  the  stitches  near  the  edge  of  the  incision.  At  (b)  the  segment  of  the 
button  is  in  place  and  the  purse-string  suture  has  been  tied.  It  is  better  to  introduce 
the  button  through  the  open  end  of  the  intestine  and  to  make  a  very  small  puncture 
of  the  wall,  just  sufficient  for  the  central  portion  of  the  button  to  protrude,  then  to 
close  the  ends  of  the  intestine.  It  will  then  not  be  necessary  to  apply  the  purse-string 
sutures  at  (a)  and  (b). 

In  uniting  small  intestine  with  small  intestine  the  end-to-end  anastomosis  with  the 
Murphy  button  is  to  be  preferred  to  the  end-to-side  or  side-to-side  anastomosis.  In 
uniting  small  intestine  with  colon  an  end-to-side  anastomosis  with  the  Murphy  button 
seems  most  satisfactory.  In  uniting  colon  with  colon  a  lateral  anastomosis  with  needle 
and  thread  or  with  the  McGraw  ligature  seems  to  give  the  most  satisfactory  results. 


GENERAL    SURGERY    OF    THE    ABDOMEN  337 

the  intestine  and  consequently  its  removal  may  result  in  a  permanent  cure.  At 
any  rate  it  is  certainly  worth"  the  effort  to  attempt  securing  such  a  result. 

It  will  be  necessary  to  remove  the  entire  ascending  colon  together  with 
the  cecum.  We  must  consequently  plan  to  secure  a  union  between  the  ileum 
and  the  transverse  colon.  We  will  first  tear  an  opening  through  the 
mesentery  of  the  ileum  an  inch  from  its  entrance  into  the  cecum.  A  strong, 
long- jawed  hemostatic  clamp  is  applied  to  the  ileum  on  the  side  toward  the 
cecum.  A  circular,  purse-string  suture  is  then  applied,  either  before  or  after 
severing  the  intestine.  If  the  intestine  is  severed  before  the  suture  is  applied 
we  prefer  to  insert  the  latter  after  the  method  illustrated  in  Plate  XXXII, 
because  this  insures  the  holding  together  of  the  two  layers  of  the  mesentery 
as  well  as  inclusion  in  the  bite  of  the  Murphy  button  of  a  uniform  amount 
of  each  layer  of  the  intestinal  wall. 

Before  severing  the  intestine  an  assistant  should  grasp  it,  at  a  distance 
of  about  six  inches  from  the  cecum,  between  his  thumb  and  finger  to  prevent 
the  leakage  of  intestinal  contents  while  the  button  is  put  in  place.  The  same 
result  may  be  accomplished  by  perforating  the  mesentery  between  the  large 
vessels  which  can  readily  be  recognized,  and  tying  a  strand  of  aseptic  gauze 
around  the  intestine  just  sufficiently  firm  to  prevent  leakage.  It  is  well  to 
draw  a  snug-fitting  pledget  of  moist  aseptic  cotton  through  the  button  to 
prevent  leakage  after  it  has  been  tied  into  the  end  of  the  intestine  and  before 
it  has  been  united  with  its  fellow.  The  smaller  portion  of  the  button  should 
be  employed  in  this  end  of  the  intestine.  The  button  is  inserted  and  the 
purse-string  suture  is  tied  snugly  about  the  projecting  central  tube  of  the 
button  and  the  ends  are  cut  short.  Now  this  end  is  laid  aside  and  covered 
with  a  warm  moist  pad  of  aseptic  gauze. 

The  cecum  is  now  lifted  out  of  the  abdominal  wound  by  means  of  the 
large  clamp  forceps  upon  the  small  portion  of  ileum  which  has  remained 
attached  to  the  cecum.  The  peritoneum  together  with  its  blood  vessels  is  now 
grasped  in  hemostatic  forceps,  both  to  the  inner  and  outer  side  of  the  cecum. 
Then  the  portion  between  is  cut  away  with  scissors.  In  this  way  the  cecum 
and  the  ascending  colon  can  be  freed  rapidly. 

As  the  operation  approaches  the  hepatic  flexure  of  the  colon  it  is  im- 
portant to  proceed  cautiously  for  fear  of  clamping  the  duodenum  together 
with  the  peritoneum  by  which  the  ascending  colon  is  attached.  In  this 
manner  the  hemorrhage  can  be  controlled  perfectly  and  the  excision  made 
rapidly.  Having  reached  the  hepatic  flexure  of  the  colon  we  are  at  least 
eight  cm.  beyond  the  tumor.  We  now  apply  two  pairs  of  heavy,  long-jawed 
hemostatic  clamps  transversely  across  the  colon  and  cut  away  the  tumor  by 
severing  the  intestine  between  the  two  clamps.  This  will  prevent  any  leakage 
from  either  end  of  the  intestine.  All  of  the  vessels  which  have  been  clamped 
are  now  carefully  ligated  with  catgut.  At  any  point  at  which  there  seems  to 
be  danger  of  the  ligature  slipping  off  it  is  best  to  place  a  catgut  suture  about 
the  part  included  in  the  grasp  of  the  hemostatic  forceps. 

It  is  well  to  bear  in  mind  the  fact  that  the  vessels  contained  in  the 
mesentery  have  a  tendency  to  retract  and  that  for  this  reason  it  is  important 
to  exercise  great  care  in  their  ligation.  The  suggestion  made  by  W.  J.  Mayo 
to  split  the  peritoneum  along  the  inner  side  of  the  intestine,  expose  the 
vessels,  clamp  and  ligate  them  is  a  very  good  one,  especially  when  the 
mesentery  is  not  definite  in  its  development,  because  in  this  way  every  pos- 
sibility of  hemorrhage  due  to  slipping  of  stump  or  retraction  of  vessels  is 
avoided. 


338 


GENERAL    SURGERY    OF    THE    ABDOMEN 


After  perfect  hemostasis  has  been  attained  a  suture  is  applied  to  the 
surface  of  the  transverse  colon  four  inches  from  its  cut  end,  as  shown  in 
Plate  XXXIII.  Care  should  be  taken  to  have  the  ascending  and  descending 
thread  in  this  suture  not  more  than  one-eighth  of  an  inch  apart.  The  intestine 
is  now  held  between  the  finger  and  thumb  of  an  assistant  six  inches  beyond 
this  point.  Its  end  is  enveloped  in  a  pad  of  moist  aseptic  gauze.  The  clamp 
which  had  up  to  the  present  time  closed  the  cut  lumen  of  the  colon  is 
removed.  Any  bleeding  points  are  caught  with  hemostatic  forceps  and  lig- 
ated.  A  short  cut,  Plate  XXXIII  a,  is  now  made  through  the  wall  of  the 
colon,  half-way  between  the  two  threads  of  the  suture.  The  Murphy  button 
is  carried  into  the  lumen  of  the  intestine  and  its  central  projecting  tube  is 
carried  out  through  the  incision  just  made.  The  ligature  is  tied  to  hold  the 
button  firmly  in  place,  although  this  is  scarcely  necessary,  because  the  open- 
ing is  just  large  enough  for  the  central  projecting  tube  of  the  button  to 
protrude.  The  open  end  of  the  colon  is  now  closed  by  two  rows  of  con- 
tinuous sutures  of  fine  silk,  the  first  row  grasping  all  of  the  layers  and  the 


Fig.  14. 

Lateral   anastomosis   following   excision   of   cecum   and   ascending   colon,   between 
lower  ileum  and  hepatic  flexure.     (Mayo.) 

second  row  of  Lembert  sutures  serving  to  invert  the  first  row  into  the  lumen 
of  the  colon.  The  pledgets  of  cotton  occluding  the  central  tube  of  the 
Murphy  button  are  now  removed  and  the  two  segments  of  the  button  are 
united. 

This  completes  the  anastomosis.  After  carefully  sponging  off  the  surfaces 
and  covering  the  defect  in  the  peritoneum,  caused  by  the  removal  of  the 
cecum  and  ascending  colon,  with  surrounding  peritoneum,  by  means  of  a 
few  catgut  stitches,  the  abdominal  wall  is  closed  in  the  usual  way. 

In  case  the  obstruction  has  been  complete  before  the  operation  so  that 
the  patient  is  so  greatly  reduced  in  strength  that  it  seems  unwise  to  expose 
him  to  a  prolonged  operation,  it  is  best  to  make  the  anastomosis  between  the 
ileum  and  the  colon  at  the  first  operation,  in  order  to  re-establish  a  satisfac- 
tory communication  and  then  to  make  the  excision  of  carcinomatous  in- 
testine after  the  patient's  strength  has  been  built  up. 


GENERAL    SURGERY    OF    THE    ABDOMEN 


339 


The  Suture  Method. 

We  have  given  so  far  the  method  which  we  used  exclusively  until  five 
years  ago  because  it  was,  in  our  hands,  most  satisfactory.  Since  that  time 
we  have,  however,  discarded  all  mechanical  means  for  securing  union  be- 
tween any  parts  of  the  gastro-intestinal  canal,  not  because  the  wonderfully 
ingenious  Murphy  button  was  unsatisfactory  in  this  especial  operation  but 
because  we  have  used  the  suture  method  hundreds  of  times,  especially  in 
gastro-enterostomies,  and  have  consequently  acquired  the  habit  of  doing 
intestinal  work  by  the  suture  method  rapidly  and  satisfactorily.  For  those 
without  much  practice  in  gastric  or  intestinal  surgery  we  believe  that  the 
above  method  is  still  the  easiest  for  the  surgeon  and  the  safest  for  the 
patient,  and  that  in  this  operation  and  in  end-to-end  enterorrhaphy  we  have 
the  only  two  operations  in  which  it  is  proper  to  use  the  Murphy  button  at 
the  present  time.  In  all  other  operations  upon  the  gastro-intestinal  tract  the 
suture  method  should  be  used  exclusively.  The  Murphy  button  must  always 
remain,  however,  a  monument  to  a  brilliant  mind  and  an  illustration  of  the 
possibilities  of  surgical  ingenuity  of  the  highest  order. 


Fig.  15. 
Murphy  Button. 

The  Murphy  Button. 

We  have  tested  the  usefulness  of  this  appliance  in  a  large  number  of 
these  operations,  and  have  found  that  it  is  most  satisfactory  if  applied 
properly.  The  important  points  to  be  borne  in  mind  in  the  use  of  the 
Murphy  button  are : 

1.  The  button  must  be  well  made  and  must  be  kept  open  while  not 
in  use,  in  order  to  prevent  injury  to  the  spring. 

2.  The  silk  suture  must  grasp  all  of  the  layers  of  the  stomach  or 
intestine,  but  it  must  be  applied  very  near  the  edge  of  the  incision  in  order 
not  to  draw  too  much  tissue  into  the  bite  of  the  button. 

3.  The  incision  through  which  the  button  is  passed  must  not  be  too 
large,  just  large  enough  for  the  button  to  pass  through. 

4.  The  purse-string  suture  holding  the  button  must  be  tied  very  tightly 
and  the  ends  cut  short,  and  it  is  best  to  arrange  the  position  of  the  knot  so 
that  the  knots  in  the  two  segments  do  not  meet. 

5.  If  there  is  any  projection  of  mucous  membrane  after  the  purse- 
string  suture  has  been  tied,  this  should  be  cut  away  before  the  two  segments 
have  been  united. 

6.  When  the  two  segments  have  been  united  there  should  be  a  perfectly 
smooth  union  throughout.    If  there  is  any  projecting  tissue  it  should  be 


34O  GENERAL    SURGERY    OF    THE    ABDOMEN 

pressed  in  between  the  segments  of  the  button  by  means  of  a  spatula  or  the 
flat  handle  of  a  scalpel. 

7.  No  sutures  should  be  applied  over  the  button. 

8.  The  button  must  be  placed  in  healthy  tissue,  never  in  the  near 
vicinity  of  an  ulcer  or  portion  of  the  intestine  which  is  in  danger  of  becoming 
gangrenous. 

Many  surgeons  object  to  the  use  of  an  appliance  which  has  to  remain 
in  the  intestine  in  the  form  of  a  foreign  body,  and  these  consequently  prefer 
a  suture  in  place  of  the  Murphy  button  or  other  appliance.  All  of  these 
operations  can  be  performed  satisfactorily  by  the  use  of  the  suture.  In  our 
own  work  we  have  usually  applied  silk  sutures  in  cases  in  which  we  did  not 
use  the  button,  but  many  surgeons  prefer  catgut. 

Rules  Governing  Sutures. 

The  same  points  must  be  borne  in  mind  in  the  use  of  sutures  as  in  the 
use  of  the  button,  namely : 

1.  The  surfaces  to  be  united  should  be  covered  with  peritoneum. 

2.  The  immediate  vicinity  of  the  attachment  of  the  omentum  should 
be  avoided. 

3.  The  two  layers  composing  the  mesentery  should  be  held  together  by 
a  carefully  applied  stitch  and  the  mesentery  in  the  two  segments  should  not 
be  placed  in  accurate  apposition. 

4.  The  first  row  of  sutures  should  grasp  all  of  the  layers  of  the  in- 
testinal wall,  but  the  needle  should  grasp  only  a  small  portion  of  each  layer. 

5.  The  second   row  of  sutures  should  be  applied  after  the   method 
known  as  Lembert  sutures,  which  penetrate  down  to,  but  not  through,  the 
mucous  membrane,  thus  placing  in  accurate  apposition  the  peritoneal  surface 
throughout  the  entire  extent  of  the  wound.    The  method  has  the  advantage 
of  affording  an  opportunity  to  make  the  anastomosis  as  large  as  one  may 
desire.   This  is  especially  advantageous  in  making  an  anastomosis  between 
portions  of  the  colon,  because  in  this  intestine  an  extensive  anastomosis  is 
desirable.    Interrupted  or  continuous   sutures  may  be  applied,  but  if  the 
latter  form  is  chosen,  it  is  well  to  take  a  back  stitch  every  fourth  or  fifth 
stitch,   in  order  to  insure  greater  security.     Plate  XXXIV  illustrates  the 
manner  in  which  the  sutures  are  applied  in  an  end-to-end  anastomosis,  but 
the  same  principle  will  apply  in  a  side-to-side  or  an  encl-to-side  anastomosis. 

After  Treatment. 

In  a  general  way  the  after  treatment  corresponds  to  that  employed  in 
gastro-enterostomy  with  the  difference  that  food  is  given  by  mouth  a  little 
earlier  and  that  active  cathartics  are  not  given  until  the  button  has  been 
passed. 

Jn  the  suture  method  cathartics  are  not  given  until  the  end  of  the 
second  week,  and  the  food  is  very  carefully  selected  to  prevent  irritation; 
predigested  foods,  buttermilk,  broth,  gruel,  egg-albumen,  are  most  useful. 

In  using  the  suture  method  in  place  of  the  Murphy  button  we  simply 
clamp,  ligate  and  invert  the  end  of  each  intestine  and  carefully  suture  it 
with  Lembert  sutures  as  shown  at  e  Plate  XXXIII,  then  we  find  a  point  at 
which  a  side-to-side  anastomosis  between  any  portion  of  the  ileum  and  the 
colon  can  be  made  without  making  tension  upon  either  intestine,  then  we 
ir.ake  an  enterostomy  at  least  five  cm.  in  length,  using  the  same  method  by 
ir.cans  of  clamps  and  sutures  that  has  been  described  in  connection  with 


PLATE  XXXIV. 

INTESTINAL  ANASTOMOSIS  :   END  TO  END  WITH   SUTURES. 

Herewith  the  manner  of  introducing  the  sutures  is  illustrated.  To  the  right  the 
suture  grasps  all  of  the  layers  of  the  intestine:  this  suture  is  first  applied.  To  the 
left  the  suture  passes  through  all  the  layers,  including  the  submucous  connective  tissue, 
hut  not  the  mucous  membrane,  then  passes  out  through  all  of  these  layers,  issuing 
near  the  edge  of  the  wound,  then  passing  in  and  out  again  on  the  opposite  side  of 
the  wound  it  is  ready  to  tie.  It  will  then  unite  two  serous  surfaces.  This  is  the 
second  row  of  sutures.  This  is  Lembert's  suture.  Above,  both  rows  are  in  place. 
but  the  outer  row  has  been  left  untied.  The  latter  is  represented  as  interrupted,  but 
continuous  sutures  may  be  u>ed  and  these  are  preferred  by  most  surgeons. 


GENERAL    SURGERY    OF    THE    ABDOMEN  343 

gastro-enterostomy.  The  only  advantage  this  operation  has  over  the  one 
with  the  Murphy  button  lies  in  the  fact  that  the  opening  can  be  made  larger 
in  this  operation  than  in  the  previous  one. 

RESECTION  OF  THE  SMALL  INTESTINE. 

This  operation  may  be  indicated  by  the  presence  of  gangrene  of  the 
intestine  in  strangulated  hernia  or  in  volvulus,  by  severe  laceration  in  gun- 
shot or  other  wounds,  by  the  presence  of  tumors  or  circumscribed  tubercu- 
losis or  occasionally  in  cases  of  intussusception  accompanied  by  gangrene.  It 
may  also  be  indicated  by  the  presence  of  cicatricial  stricture  or  intestinal 
fistula.  The  operation  itself  is  very  simple  and  more  depends  upon  the 
proper  selection  of  tissue  than  upon  the  technique  of  the  operation  itself. 
Whenever  the  operation  is  performed  in  the  presence  of  gangrene  care  must 
be  taken  to  go  a  considerable  distance  beyond  the  suspicious  tissue.  A  patient 
is  much  safer  if  one  yard  of  intestine  has  been  sacrificed  unnecessarily,  than 
he  would  be  if  the  excision  were  made  at  the  very  border  of  the  gangrenous 
tissue. 

Technique. 

In  excising  diseased  intestine  it  is  well  to  grasp  the  mesenteric  vessels 
carefully  as  one  progresses  and  to  ligate  them  before  resecting  the  intestine. 
In  case  it  does  not  seem  safe  to  apply  simple  ligatures  the  mesentery  may  be 
transfixed  with  sutures,  in  order  to  prevent  slipping. 

After  a  sufficient  amount  of  intestine  has  been  separated  from  its  at- 
tachment to  the  mesentery,  care  is  taken  to  stop  at  a  point  sufficiently  distant 
from  a  large  branch  of  the  mesenteric  artery  to  prevent  the  injury  of  the 
latter.  The  intestine  is  now  held  on  either  side  by  the  hand  of  an  assistant 
to  prevent  leakage,  or  this  may  be  done  by  passing  a  narrow  strip  of  gauze 
through  the  mesentery  and  tying  just  tightly  enough  to  prevent  extrusion. 
Then  a  large  pair  of  long-jawed,  clamp  forceps  is  applied  to  either  side  of 
the  portion  to  be  excised,  in  order  to  prevent  leakage  from  this  portion.  Then 
the  intestine  is  cut  away  at  either  side,  care  being  taken  to  cut  away  a  little 
more  from  the  point  opposite  the  mesentery  than  on  the  mesenteric  side. 

Aside  from  protecting  the  tissue  against  gangrene  this  method  results 
in  a  little  increase  in  lumen  at  the  point  at  which  the  enterorrhaphy  is  made, 
which  is  probably  of  importance  especially  in  cases  in  which  this  is  accom- 
plished by  the  suture  method.  When  the  Murphy  button  is  used  there  is 
never  any  narrowing  at  the  point  of  union,  because  the  cicatricial  tissue 
formed  is  so  slight  that  it  can  hardly  be  discovered  by  the  unaided  eye. 

Silk  stitches  are  then  applied,  as  illustrated  in  Plate  XXXII.  being 
cautious  to  pass  the  stitch  around  the  mesentery  so  as  to  hold  its  two  surfaces 
together.  The  larger  segment  of  the  Murphy  button  is  adjusted  to  the  lower 
segment  and  the  smaller  one  to  the  upper  and  then  the  two  segments  are 
adjusted  to  each  other.  It  is  well  to  turn  them  a  little  so  that  the  mesentery 
of  the  one  part  does  not  fall  directly  opposite  to  the  mesentery  of  the  other. 
A  few  sutures  should  be  applied  to  cover  the  defect  caused  by  the  excision  of 
the  intestine  in  order  to  prevent  unnecessary  adhesions  to  the  denuded  sur- 
faces. 

In  this  operation  we  now  use  the  suture  method  exclusively,  applying 
one  row  of  sutures  which  grasps  all  of  the  layers  to  secure  accurate  coapta- 
tion  and  to  control  the  hemorrhage.  This  row  of  sutures  carefully  brings 


344  GENERAL    SURGERY    OF    THE    ABDOMEN 

together  the  mesenteric  attachment  so  as  to  prevent  leakage  at  this  point.  A 
second  row  of  continuous  Lembert  sutures  is  applied  over  the  first  row  of 
sutures  in  order  to  unite  peritoneum  to  peritoneum  throughout.  This  method 
was  introduced  by  Czerny  many  years  ago  and  is  still  very  satisfactory. 

Gregory  Connell  has  introduced  the  following  method  which  is  also  most 
excellent  although  it  requires  somewhat  more  dexterity  and  accuracy  than 
that  just  described. 

The  Connell  Method. 

Nothing  can  be  more  perfect  for  an  end-to-end  anastomosis  of  the  small 
intestine  than  this  operation  when  performed  by  its  author  or  by  any  one  who 
has  operated  sufficiently  often  upon  animals  to  obtain  a  similar  degree  of 
accuracy.  Each  successive  suture  leaves  the  serous  surfaces  in  ideal  coapta- 
tion,  as  shown  by  the  accompanying  illustrations,  and  when  the  operation 
has  been  completed  every  suture  is  perfectly  buried.  There  can  be  no  hemor- 
rhage because  the  sutures  grasp  every  portion  of  the  intestinal  wall.  The 
mesenteric  attachment  has  been  closed  so  that  there  can  be  no  perforation 
at  this  treacherous  point  and  there  is  no  possibility  of  obstruction  at  the  point 
of  union  between  the  two  segments.  The  operation  is,  however,  too  difficult 
technically  to  be  undertaken  by  an  unskilled  surgeon,  who  might  still  be 
able  to  safely  close  both  ends  of  the  intestine  and  make  the  lateral  anastom- 
osis described  above. 

Steps  of  the  Operation. 

The  various  steps  of  the  operation  have  been  so  accurately  described  by 
Gregory  Connell,  its  author,  in  connection  with  his  illustrations  that  it  seems 
impossible  to  misunderstand  any  detail,  and  in  order  to  acquire  the  necessary 
skill  to  perform  this  operation  it  is  but  necessary  to  do  it  repeatedly  upon 
dogs. 

A  dozen  operations  can  safely  be  made  upon  a  single  animal  if  the 
surgeon  will  work  as  rapidly  as  he  can,  and  if  ether  is  administered  carefully 
to  the  animal  it  consequently  will  not  require  many  animals  to  acquire  pro- 
ficiency. 

The  excision  of  the  diseased  portion  having  been  made  and  the  bleeding 
from  the  mesenteric  attachment  controlled  the  first  suture  is  applied  from 
within  outward,  indicated  in  Fig.  i,  Plate  XXXV,  just  outside  of  the  mesen- 
teric attachment,  then  it  is  carried  across  to  the  other  side  and  passed  from 
without  inward  again  just  outside  of  the  mesentery,  then  it  is  carried  across  to 
the  other  side  and  is  passed  into  the  lumen  of  the  intestine  where  the  suture 
is  tied,  perfectly  closing  the  mesenteric  attachment.  The  sutures  from  this 
point  on  are  applied  as  indicated  in  the  illustrations,  on  Plates  XXXV  and 
XXXVI. 

RESECTION  OF  THE  COLON. 

Should  it  become  requisite  to  resect  the  colon  we  are  confronted  with  a 
condition  which  is  somewhat  different,  inasmuch  as  the  posterior  surface  of 
the  colon  is  not  covered  with  peritoneum.  This  makes  an  anastomosis  much 
more  troublesome,  because  union  is  much  less  certain  in  portions  of  the 
intestine  not  covered  with  peritoneum.  In  order  to  overcome  this  difficulty 
it  is  best  to  close  the  ends  of  the  colon  and  make  a  side-to-side  anastomosis 
of  the  two  ends,  choosing  for  this  the  surfaces  covered  with  peritoneum, 
as  illustrated  in  Plate  XXXIII. 

In  the  transverse  colon  it  is  especially  important  not  to  infringe  upon 


1.     Insertion  of  mesenteric  stitch,  which  ob- 
literates triangular  space. 


2.  Mesenteric  stitch,  and  stitch  at  convex 
border  inserted  and  tied,  with  ends  left  long 
for  traction.  Intervening  stitches  in  place. 


3.  First,  posterior,  half  completed, 
with  first  stitch  in  second,  anterior,  half 
inserted,  ready  for  tying. 


4.  Stitches  similar  to  one  shown  in 
Fig.  3,  inserted  throughout  the  anterior 
half,  all  tied  but  the  last  stitch.  This 
in  place,  with  ends  ready  for  tying. 


5.  Threaded  needle  is  inserted  eye 
first  between  two  stitches  into  the  lumen, 
at  a,  point  in  the  circumference  about 
opposite  to  the  stitch  to  be  tied. 


PLATE  XXXV. 

Illustrating  the  Connell  Method  of  Suturing.     (Courtesy  of  Gregory  Connell.) 


6.  The  threaded  needle  presents  at 
the  location  of  the  last  stitch.  The 
ends  to  be  tied  are  inserted  into  the 
loop  formed  by  the  needle  and  its 
thread. 


7.  By  withdrawal  of  the  needle 
and  its  loop,  the  cut  ends  at  the  site 
of  the  last  stitch  are  inverted,  and 
the  ends  to  be  tied  are  drawn  to  the 
outside  through  the  opposite  portion 
of  the  line  of  suture. 


8.  Traction  on  suture  ends  causes  the 
site  of  the  future  knot  to  come  in  con- 
tact with  the  mucosa  of  the  opposite  side 
of  the  bowel.  The  ends  are  tied,  the 
knot  sinks  between  the  previously  in- 
serted stitches  and  is  located  on  the 


9.  The  last  knot  is  tied,  the 
bowel  has  resumed  its  cylindrical 
contour,  and  the  enterorrhaphy  is 
complete,  with  all  knots  in  the 
lumen. 


PLATE  XXXVI. 
Illustrating  the  Connell  Method  of  Suturing.     (Courtesy  of  Gregory  Council.) 


GENERAL    SURGERY    OF    THE    ABDOMEN  349 

the  attachment  of  the  omentum  for  fear  of  causing  subsequent  necrosis.  This 
anastomosis  should  never  be  made  by  means  of  a  Murphy  button,  as  there 
is  liable  to  be  an  accumulation  of  hardened  feces  in  the  upper  segment,  which 
would  be  likely  to  obstruct  the  lumen  of  the  button,  for  this  reason  it  seems 
best  always  to  make  an  anastomosis  by  means  of  suturing.  It  is  usually  still 
better  to  close  both  ends  of  the  large  intestine  and  make  an  anastomosis  be- 
tween the  ileum  and  the  colon  below  the  point  of  resection,  as  in  this  way 
one  secures  the  flow  of  liquid  contents  of  the  small  intestine  into  the  colon. 
In  this  case  the  button  is  perfectly  safe  but  we  now  always  use  the  suture. 

If  this  plan  is  followed  it  is  best  to  excise  all  of  the  colon  on  the  proximal 
side  of  the  malignant  growth  to  prevent  accumulation  of  fecal  material  in 
this  portion  and  it  is  usually  most  convenient  to  make  the  anastomosis  be- 
tween the  ileum  and  the  sigmoid  flexure,  because  at  this  point  the  anastomosis 
can  be  effected  without  any  tension  upon  either  segment. 

The  end  of  the  colon  is  closed  by  applying  a  strong  pair  of  forceps 
across  the  intestine  at  the  point  at  which  the  resection  is  contemplated.  This 
will  -crush  the  soft  tissues  out  of  the  grasp  of  the  forceps  and  leave  only  the 
fibrous  tissue  in  place.  Then  a  silk  purse-string  suture  is  applied  to  the 
proximal  side  of  these  forceps.  This  is  tied  tightly,  which  will  cause  it  to  be 
buried  in  the  groove  made  by  the  heavy  forceps.  Then  the  diseased  portion 
is  cut  away,  leaving  the  portion  of  the  tissue  held  by  the  purse-string  suture 
to  project  from  the  part  of  the  intestine  which  is  left.  This  is  then  buried 
in  the  end  of  the  intestine  by  the  application  of  a  row  of  Lembert  sutures. 

Gibson  Method. 

The  most  satisfactory  operation  for  end-to-end  anastomosis  of  the 
lower  end  of  the  colon  that  we  have  employed  is  that  introduced  by  C.  L. 
Gibson  which  we  will  describe  in  his  own  words. 

The  method  has  the  advantage  of  extreme  simplicity.  It  provides  for 
a  broad  union  of  peritoneal  surfaces  and  it  reduces  the  tension  necessary  to 
a  minimum. 

The  anastomosis  does  not  result  in  any  narrowing  at  the  line  of 
suturing. 

"The  upper  cut  edge  of  the  gut  is  seized  with  two  Kocker  clamps  and 
introduced  by  these  into  the  lumen  of  the  lower  end  and  maintained  there 
by  an  assistant.  The  extent  to  which  it  is  feasible  to  accomplish  this  invag- 
ination  will  vary,  depending  on  the  laxity  of  the  mesentery.  If  the  latter  is 
very  short  it  may  be  elongated  somewhat  by  a  generous  incision  of  its  outer 
layer.  As  a  general  rule  I  should  wish  to  carry  the  cut  end  of  the  upper 
segment  so  far  down  as  possible,  hoping  more  efficiently  to  direct  the  fecal 
current  away  from  the  suture  line.  The  gut  is  rotated  about  a  quarter  circle 
so  that  the  non-peritoneal  covered  surfaces  do  not  entirely  approximate  in 
the  circumference.  Eight  to  twelve  interrupted  silk  sutures  are  introduced 
thus.  A  Lembert  suture  is  begun  on  the  lower  segment,  the  needle  issuing 
just  short  of  the  cut  edge;  on  the  upper  segment  the  needle  is  introduced 
just  above  the  line  where  the  cut  edge  of  the  lower  segment  lies  against  the 
intact  wall  of  the  upper.  When  the  knot  is  tied  the  free  cut  edge  has  been 
turned  inward  and  only  the  peritoneal  surfaces  are  in  contact.  A  continuous 
running  suture  is  applied  over  this  area  further  invaginating  the  first  ones, 
the  Kocher  clamps  being  previously  withdrawn." 

After  Treatment. 

In  a  general  way  the  after-treatment  in  which  the  colon  is  involved  in 


35°  GENERAL    SURGERY    OF    THE    ABDOMEN 

the  operation  is  the  same  as  in  operations  upon  the  stomach  or  the  small  in- 
testines ;  only  predigested  foods  are  given  by  mouth  from  the  third  day  on 
and  nourishment  by  enema  is  not  employed.  Hot  water  in  small  sips  is 
given  by  mouth  shortly  after  the  operation  and  continued  for  the  first  few 
days. 

One  can  easily  choose  a  predigested  food  which  is  absorbed  almost 
entirely  from  the  stomach  and  small  intestines  which  will  sustain  the  patient 
until  the  union  between  the  joined  ends  of  intestine  is  sufficiently  firm  to 
make  the  use  of  general  liquid  diet  safe.  Ordinarily  a  very  firm  union  exists 
after  the  third  day,  but  occasionally  the  patients  in  whom  these  operations 
are  indicated  are  much  reduced  in  strength  and  consequently  their  tissues  do 
not  heal  so  rapidly. 

INGUINAL  COLOSTOMY. 

The  only  pathological  condition  indicating  an  inguinal  colostomy  is  a 
stricture  of  the  rectum  which  cannot  be  excised.  This  may  be  due  to  carcin- 
oma or  cicatricial  contraction  following  a  tubercular  or  a  syphilitic  ulcer,  or 
an  acute  infection. 

The  operation  may  be  intended  only  for  temporary  relief  until  the  con- 
stricted portion  of  the  rectum  may  be  excised  and  the  continuity  between  the 
intestine  above  and  below  this  constriction  has  again  been  established,  or  it 
may  be  for  permanent  use.  If  it  is  intended  only  for  temporary  effect  it  is 
not  necessary  to  provide  for  a  means  of  keeping  this  opening  closed  at  times 
to  guard  against  the  involuntary  evacuation  of  the  bowels.  If  the  intestine 
is,  however,  intended  to  remain  permanently  open,  it  is  desirable  to  secure 
such  a  provision.  For  the  sake  of  brevity  we  describe  only  the  latter  opera- 
tion, because  it  happens  frequently  that  a  colostomy  which  is  primarily  in- 
tended to  be  only  for  temporary  relief  will  later  be  maintained  permanently, 
either  because  it  is  not  possible  to  establish  a  satisfactory  communication 
through  the  natural  way,  or  because  the  patient  is  so  comfortable  that  he 
refuses  to  submit  to  the  necessary  operation  to  establish  the  communication 
through  the  rectum. 

Technique. 

An  incision  is  made  parallel  with  Poupart's  ligament,  two  and  one-half 
inches  in  length,  two  inches  above  the  anterior  superior  spine.  Its  center  is 
crossed  by  a  line  extending  from  the  left  anterior  superior  spine  of  the  ilium 
to  the  umbilicus.  This  line  extends  down  through  the  external  oblique  ab- 
dominal muscle,  whose  fibers  it  separates  but  does  not  cut. 

The  internal  oblique  abdominal  muscle  is  then  separated  in  the  direction, 
of  its  fibers,  which  extend  nearly  at  right  angles  with  the  fibers  of  the  ex- 
ternal oblique.  Then  the  transversalis  fascia  and  peritoneum  are  severed  in 
the  same  direction.  This  incision  corresponds  exactly  to  the  McBurney  in- 
cision, which  has  been  described  in  the  section  on  appendicitis,  with  the 
exception  that  it  is  on  the  left  instead  of  the  right  side  of  the  abdomen. 
With  this  incision  the  two  abdominal  muscles  are  not  impaired,  because  none 
of  their  fibers  have  been  cut  at  right  angles,  and  they  are  in  a  condition  in 
which  they  can  readily  act  as  sphincter  muscles. 

A  second  incision  is  now  made  parallel  with  the  first  and  of  the  same 
length,  but  four  cm.  nearer  the  anterior  superior  spine  of  the  ilium.  A  third 
incision  uniting  these  two  at  the  upper  end  is  made  and  the  flap  of  the  skin 
thus  formed  is  dissected  loose  and  covered  temporarily  by  a  piece  of  moist 


END-TO-END   ANASTOMOSIS   OF  COLON. 

1.     The  intestine  is  clamped  with  large  forceps  whose  jaws  are  covered  with  rub- 
ber tubing  to  prevent  injury  to  tissues.    By  courtesy  of  Dr.  C.  L.  Gibson. 


END-TO-END  ANASTOMOSIS    OF   COLON. 

2.  The  upper  segment  is  invaginated  into  the  lower  and  a  Lembert  suture  has 
been  applied  which  will  invert  the  cut  end  of  the  lower  segment  when  tied.  By  cour- 
tesy of  Dr.  C.  L.  Gibson. 


PLATE  XXXVII. 


END-TO-END   ANASTOMOSIS    OF   COLON. 


3.     The  compressing  forceps   have  been   removed   and  the  cut   end   of   the  lower 
segment  inverted.     By  courtesy  of  Dr.  C.  L.  Gibson. 


END-TO-END   ANASTOMOSIS    OF   COLON. 


4.     The  completed  operation  with  exception  of  tying  sutures  and  introducing  fur- 
ther sutures  of  the  same  kind.     By  courtesy  of  Dr.  C.  L.  Gibson. 


PLATE  XXXVIIT. 


GENERAL    SURGERY    OF    THE    ABDOMEN  355 

antiseptic  gauze.  The  finger  is  then  inserted  into  the  abdominal  cavity  and 
passed  along  the  ilium  until  it  reaches  the  sigmoid  flexure  of  the  colon.  This 
is  withdrawn  through  the  incision  in  the  abdominal  wall.  It  can  readily  be 
recognized  as  large  intestine  from  the  fact  that  the  longitudinal  band  of 
muscle  fibers  extends  parallel  with  its  upper  surface  and  that  there  are  at- 
tached to  it  numerous  masses  of  fat,  the  appendices  epiploica.  It  is  best  to 
bring  out  the  upper  segment  of  the  sigmoid  as  much  as  possible,  in  order  to 
prevent  it  from  prolapsing  later  on,  a  condition  which  occurs  frequently  in 
cases  in  which  this  precaution  has  not  been  taken. 

The  intestine  is  now  held  up  to  the  light  in  order  to  select  a  point  in 
its  mesentery  through  which  an  opening  may  be  torn  without  disturbing  any 
of  the  large  blood  vessels.  This  opening  must  be  sufficiently  large  to  admit 
the  skin  flap  which  has  been  prepared.  The  upper  segment  of  the  intestine 
is  then  placed  outward  and  the  lower  segment  inward  and  the  skin  flap  is 
drawn  through  the  opening  in  the  mesentery.  In  this  manner  the  upper  seg- 
ment is  bent  over  the  outer  edge  of  the  abdominal  wall  and  underneath  the 
skin  flap.  Consequently,  after  healing  has  taken  place  the  application  of  a 
pad  over  this  part  will  cause  the  skin  flap  to  act  like  a  valve  and  will  prevent 
the  involuntary  evacuation  of  the  bowel  contents.  The  incisions  are  now 
closed.  In  order  to  prevent  any  protrusion,  a  few  stitches  are  inserted  at- 
taching the  intestine  to  the  skin.  The  operation  is  shown  in  Plate  XXXIX. 

The  loop  of  intestine  is  not  opened  until  adhesions  have  formed,  unless 
this  is  necessary  on  account  of  complete  obstruction,  in  which  case  the  wound 
is  carefully  protected  and  a  large  rubber  tube  covering  a  short  glass  tube  is 
inserted  into  the  upper  segment  and  securely  fastened  by  means  of  a  strong 
purse-string  suture.  This  will  compel  the  contents  of  the  intestine  to  pass 
out  through  the  tube,  which  is  passed  through  the  dressing,  without  soiling 
the  wound.  If  this  is  not  necessary  a  dressing  is  applied  which  will  permit 
the  gas  to  pass  through  this  loop.  Cotton  is  rolled  in  long  bundles  and  these 
are  applied  about  the  protruding  intestine  after  the  fashion  of  logs  in  a  log 
cabin.  These  bundles  are  held  in  place  by  means  of  broad  adhesive  strips 
and  an  abdominal  bandage. 

After  from  two  to  five  days  the  intestine  is  cut  across  and  then  the 
evacuations  can  occur  without  interfering  with  the  healing  of  the  wound. 
Aside  from  the  advantage  there  is  in  securing  a  means  of  closing  the  upper 
segment  when  desired,  this  method  has  the  further  value  of  leaving  the  two 
openings  of  the  intestine  so  far  apart  that  there  can  be  no  passage  of  feces 
from  the  upper  into  the  lower.  The  evacuations  will  now  occur  through  the 
opening  a,  which  is  sufficiently  separated  from  the  opening  b,  communicating 
with  the  segment  leading  to  the  rectum,  to  prevent  any  of  the  evacuations 
from  finding  their  way  into  this  canal.  This  portion  of  the  intestine  can, 
however,  be  cleansed  by  irrigating  through  this  opening. 

In  case  it  should  become  desirable  later  on  to  close  the  artificial  anus 
this  may  be  accomplished  by  inserting  one  branch  of  a  clamp  through  each 
of  these  openings  and  gradually  tightening  the  pressure  until  a  communica- 
tion has  been  established,  when  the  openings  can  readly  be  closed. 

After  Treatment. 

Until  the  protruding  loop  has  been  cut  only  hot  water  and  small  quan- 
tities of  predigested  food  are  given  by  mouth.  After  this  time  general 
liquids,  and  after  a  week  light  diet  is  given. 

This  operation  is  usually  performed  in  old  persons  greatly  reduced  in 


356  GENERAL    SURGERY    OF    THE    ABDOMEN 

strength  and  such  do  not  well  bear  lying  quietly  in  bed.  It  is  consequently 
best  to  permit  them  to  occupy  a  semi-sitting  position  within  a  day  or  two 
after  the  operation,  and  to  leave  the  bed  within  a  week  or  ten  days  later. 

After  the  intestine  has  been  opened  a  cathartic,  preferably  castor  oil, 
should  be  given,  and  this  should  be  followed  by  several  enemata  in  order  to 
remove  fecal  accumulations  which  frequently  exist  in  large  quantities  above 
the  constriction,  even  if  a  diligent  attempt  has  been  made  to  evacuate  the 
bowels  before  the  operation.  Frequently  the  lower  segment  contains  many 
of  these  masses,  which  may  usually  be  removed  by  irrigation  but  may  occa- 
sionally require  a  blunt  scoop.  It  is  well  to  examine  the  opening  by  inserting 
the  finger  within  the  lumen  of  the  intestine  through  the  abdominal  wall, 
because  occasionally  not  sufficient  space  has  been  allowed  for  the  evacuation 
of  the  bowels  and  the  free  passage  of  gas.  This  can  be  remedied  readily  by 
a  slight  incision. 

These  patients  should  be  instructed  to  regulate  their  diet  so  as  to  avoid 
constipation  and  then  to  take  a  simple  cleansing  enema  once  a  day  to  insure 
a  free  evacuation  of  the  bowels.  Thus  they  can  usually  be  entirely  free  from 
any  annoyance  because  of  the  artificial  anus.  A  small  pad  of  cotton  should 
be  worn  over  the  opening,  held  in  place  by  a  simple  abdominal  bandage.  In 
case  there  is  any  annoyance  from  escaping  feces  a  substantial  pad  may  be 
held  in  place  over  the  opening  by  means  of  an  elastic  bandage,  which  will 
compress  the  intestine  underneath  the  skin  flap  Plate  XXXIX  c,  over  the 
edge  of  the  abdominal  wound  sufficiently  to  overcome  this  annoyance. 

If  there  is  not  enough  force  in  the  colon  to  produce  an  evacuation,  it 
is  sometimes  best  to  insert  a  large  rectal  tube  after  giving  the  enema  and  to 
effect  the  evacuation  through  this. 

In  cases  in  which  it  is  plain  at  the  time  of  the  operation  that  it  will 
never  be  possible  to  re-establish  communication  between  the  upper  and  lower, 
segments,  on  account  of  the  obstruction  in  the  rectum,  we  prefer  to  perform 
an  operation  which  carries  out  the  upper  segment  through  the  abdomnial 
wall.  This  is  required  especially  in  cases  of  carcinoma  in  which  the  growth 
has  invaded  the  surrounding  tissues  to  such  an  extent  that  a  complete  re- 
moval is  impossible. 

In  this  operation  the  first  steps  are  the  same  as  those  described  above 
but  instead  of  forming  a  skin  flap  to  carry  underneath  the  loop  of  intestine 
the  second  incision,  five  cm.,  is  made  parallel  to  the  first  and  the  skin  and 
superficial  fascia  are  undermined  so  as  to  form  a  tunnel  through  which  the 
upper  segment  of  the  colon  is  later  to  be  carried,  then  the  abdomen  is  opened 
a  second  time  through  a  median  incision  ten  to  fifteen  cm.  long  between  the 
umbilicus  and  the  pubis.  The  sigmond  flexure  is  brought  out  through  this 
opening,  its  mesentery  is  clamped  and  ligated  according  to  the  method  de- 
scribed in  excision  of  the  colon.  About  ten  to  fifteen  cm.  of  the  intestine 
is  made  free  from  the  mesentery,  then  two  large  clamps  are  applied  trans- 
versely, at  a  point  leaving  enough  tissue  in  connection  with  the  lower  seg- 
ment to  make  sure  that  the  upper  segment  is  at  least  ten  cm.  beyond  any 
diseased  tissue  and  at  the  same  time  enough  to  make  an  inversion  of  the 
free  end  of  this  segment  into  its  lumen  easily  possible.  The  upper  segment 
must  contain  a  sufficient  amount  of  free  bowel  to  reach  through  the  inguinal 
opening  and  through  the  canal  underneath  the  skin  flap,  and  beyond  the 
margin  of  the  second  incision,  without  the  slightest  tension. 

The  end  of  the  lower  segment  is  then  ligated  and  inverted  into  its  lumen 


PLATE  XXX IX. 

INGUINAL  COLOSTOMY. 

The  colon  is  drawn  out  through  the  incision  in  the  abdominal  wall ;  its  mesentery 
is  split :  a  rectangular  flap  of  skin  is  cut  and  drawn  through  the  slit  in  the  mesentery 
and  sutured  in  place.  The  longitudinal  muscular  band  is  shown  upon  the  surface  of 
the  sigmoid  flexure  of  the  colon. 

The  intestine  will  be  cut  across  at  the  point  indicated  by  the  dotted  line,  the  open- 
ings will  then  retract  to  the  points  a  and  b. 


GENERAL    SURGERY    OF    THE    ABDOMEN  359 

and  the  wall  closed  over  it  with  a  purse-string  suture  which  is  reinforced 
with  a  row  of  Lembert  sutures. 

The  upper  segment  is  then  also  ligated  to  prevent  the  escape  of  any 
contents,  then  it  is  carefully  covered  with  gauze  and  carried  out  through 
the  inguinal  incision  and  underneath  the  skin  flap  where  it  is  sutured  in 
place,  so  as  to  project  at  least  one  cm.  beyond  the  surface  of  the  skin.  A 
few  sutures  are  applied  between  the  wall  of  the  bowel  and  the  peritoneum 
and  transversalis  fascia  at  the  inguinal  wound  in  order  to  support  the  seg- 
ment and  at  the  same  time  to  prevent  any  loop  of  the  small  intestine  from 
being  forced  out  along  the  side  of  the  colon. 

Then  the  wounds  are  all  sutured  and  the  same  dressing  is  applied  as  in 
the  previous  operation. 

It  is  important  to  determine  which  is  the  proximal  and  which  the  distal 
segment  because  in  these  cases  with  long-continued  obstruction  the  sigmoid 
flexure  is  often  very  long  and  sometimes  twisted  upon  its  mesentery  so  that 
it  is  quite  possible  to  confound  the  two  segments.  This  would,  of  course,  be 
a  fatal  error  unless  it  were  discovered  in  time  to  be  remedied. 

The  after-treatment  is  the  same  as  in  the  previous  operation,  the  liga- 
ture closing  the  upper  segment  is  removed  on  the  second  or  third  day.  It 
is  important  in  this  operation  not  to  permit  any  fecal  matter  to  remain  in 
the  lower  segment  above  the  point  of  constriction,  as  this  might  result  in 
perforation. 

In  many  of  these  cases  the  removal  of  irritation  caused  by  the  passage 
of  fecal  material  over  the  surface  of  the  carcinoma  will  cause  the  malignant 
growth  to  remain  stationary  in  its  development  for  a  long  time. 

We  have  seen  many  of  these  patients  take  on  a  normal  appearance,  gain 
greatly  in  weight,  return  to  their  occupation  and  imagine  themselves  cured 
for  months  or  even  years.  This  is  true  especially  in  cases  of  very  slow 
growing  annular  carcinoma  of  the  rectum  in  which  the  bad  condition  of  the 
patient  is  due  to  prolonged  absorption  of  fecal  material  which  had  accumu- 
lated above  the  seat  of  obstruction  before  this  condition  was  relieved  by 
establishing  a  colostomy. 

ARBUTHNOT  LANE'S  SURGICAL  TREATMENT  FOR  CONSTIPATION. 

Several  years  ago  our  attention  was  directed  by  Lane  to  the  fact  that 
many  patients  suffer  severely  from  the  results  of  absorption  of  putrid  sub- 
stances from  a  colon  containing  enormous  quantities  of  fecal  matter  pre- 
vented from  being"  evacuated  normally.  Lane  demonstrated  the  fact  that 
these  accumulations  remain  indefinite  periods  of  time,  the  evacuations  that 
may  occur  from  time  to  time  never  emptying  more  than  the  lowest  portion, 
and  frequently  passing  directly  by  the  accumulations  in  the  colon  on  their 
way  from  the  ileum  to  the  rectum. 

This  condition  is  due  to  faulty  development  as  regards  the  position  espe- 
cially of  the  cecnm  and  transverse  colon,  the  latter  usually  having  its  position 
low  down  in  the  abdominal  cavity.  It  is  further  exaggerated  by  constricting 
or  obstructing  bands,  and  still  further  by  habitual  neglect  on  the  part  of  the 
patient  to  secure  regular,  complete  daily  evacuation  of  the  bowels. 

When  the  transverse  colon  and  the  cecum  have  once  become  perma- 
nently loaded  with  hardened  feces  the  weight  of  the  mass  itself  will  result 
in  the  dropping  down  of  the  cecum  and  transverse  colon,  and  this  in  turn  will 
serve  to  still  further  increase  the  condition  of  constipation. 


360  GENERAL    SURGERY    OF    THE    ABDOMEN 

In  many  of  these  cases  Lane  has  obtained  remarkable  results,  restoring 
patients  who  were  complete  physical  and  nervous  wrecks  to  good  health  and 
strength  by  excising  the  entire  colon  and  implanting  the  ileum  into  the  sig- 
moid  or  into  the  upper  portion  of  the  rectum ;  or  in  milder  cases  by  resecting 
the  ileum  fifteen  cm.  from  its  entrance  into  the  cecum  and  implanting  the 
proximal  end  into  the  sigmoid  flexure. 

The  following  description  of  the  various  steps  of  the  operation  is  taken 
from  Lane's  work  on  this  subject.  We  have  performed  the  operation  three 
times  with  satisfactory  results  and  have  seen  a  number  of  Lane's  patients, 
all  of  whom  showed  excellent  recoveries. 

Lane's  Technique. 

"In  no  circumstances  should  operative  interference  be  contemplated  till 
the  surgeon  has  satisfied  himself  that  every  other  means  of  treatment  have 
failed,  whether  medical  or  mechanical. 

"In  the  treatment  of  such  degrees  of  overloading  of  the  large  bowel  as 
cannot  be  treated  efficiently  by  measures  short  of  operation,  I  have  obtained 
considerable  success  by  dividing  constricting  bands  and  adhesions,  and  by 
subsequent  careful  attention  to  the  proper  functioning  of  the  bowel.  In  a 
considerable  proportion  of  cases,  and  more  particularly  in  women,  such 
means  are  insufficient,  as  at  the  best  they  only  afford  temporary  relief,  since 
the  obstruction  recurs  sooner  or  later. 

"In  my  earliest  cases,  after  the  appendix  had  been  removed  and  the 
cecum  and  flexures  freed  from  adhesions  on  one  or  more  occasions,  with 
transitory  benefit,  I  looked  about  for  some  means  of  relieving  the  patients 
of  the  cecal  pain  from  which  they  suffered  and  for  the  relief  of  which  they 
were  ready  to  submit  to  any  operation.  Pain  was  the  chief  symptom  of 
which  they  complained. 

"In  the  first  case  I  merely  made  a  lateral  anastomosis  between  the  ileum 
and  sigmoid,  but  the  early  return  of  cecal  pain  obliged  me  to  divide  the 
ileum.  In  several  of  the  cases  in  which  I  had  divided  the  ileum,  after  an 
interval  of  months  the  patients  were  occasionally  annoyed  by  the  presence  of 
hard,  dry  masses  of  fecal  matter  in  the  cecum.  They  produced  no  auto- 
intoxication, but  the  discomfort  arising  from  their  presence  and  from  flatu- 
lent distension  was  sufficient  to  call  for  the  removal  of  the  large  bowel  as 
far  as  the  splenic  flexure.  These  hard  masses  of  feculent  material  are  not 
necessarily  the  result  of  regurgitation,  but  are  probably  formed  in  the  large 
bowel.  A  still  more  extended  experience  showed  me  that  if  any  portion  of 
the  large  bowel  is  left  above  the  junction  with  the  ileum  it  tends  to  dilate 
sooner  or  later.  This  dilatation  may  interfere  with  the  satisfactory  evacua- 
tion of  feces,  and  discomfort  or  pain  may  ensue  because  of  its  distension  by 
fecal  matter  or  gas.  Therefore,  to  overcome  completely  the  constipation  as 
well  as  the  septic  absorption,  the  large  bowel  should  be  removed  as  far  as  its 
junction  with  the  ileum,  which  is  effected  in  the  upper  part  of  the  rectum  or 
in  the  adjacent  sigmoid. 

"Therefore,  when  I  recognize  that  the  mechanics  of  the  intestines  have 
been  altered  to  a  degree  that  cannot  be  rectified  satisfactorily  by  the  division 
of  bands,  etc.,  I  divide  the  ileum  at  a  distance  of  about  five  or  six  inches 
from  the  cecum.  This  can  be  clone  rapidly  and  securely  by  encircling  it  by 
means  of  a  catgut  ligature. 

''The  ileum  is  divided  by  the  cautery  immediately  beyond  the  ligature. 
The  stump  is  then  buried  in  the  proximal  bowel  by  means  of  a  purse-string 


1.     Showing  tube  introduced  through  the  rectum  up  into  proximal  sigmoid,  and 
placing  of  catgut  suture. 


: 


2.     Showing  tube  used   for  bringing  the  two  ends  into  apposition,  and  first  row 
of  sutures  placed. 


3.     Showing  intussusception  accomplished  and  outer  row  of  sutures  placed. 

PLATE  XL. 


GENERAL    SURGERY    OF    THE    ABDOMEN  363 

suture  which  encircles  the  bowel  and  perforates  its  peritoneal  and  muscular 
coats  about  three-quarters  of  an  inch  above  its  ligatured  extremity,  rendering 
the  closure  absolutely  secure. 

"The  acquired  adhesions  and  peritoneum  which  bind  the  cecum  and 
ascending  colon  to  the  abdominal  wall  external  to  them  are  divided,  and 
the  bowel  is  raised  till  the  vessels  which  supply  it  are  exposed.  These  are 
grasped  in  compression  forceps  and  firmly  ligatured.  The  vessels  supplying 
the  transverse  colon  are  similarly  treated,  and  finally  the  descending  colon 
and  perhaps  the  sigmoid  are  removed,  the  upper  limit  of  the  rectum  or  the 
lower  part  of  the  sigmoid  being  occluded  in  the  same  manner  as  the  ileum. 

"Originally  I  had  been  satisfied  to  divide  the  transverse  colon  at  the 
splenic  flexure,  closing  the  distal  portion  in  the  manner  already  described,  but 
for  the  reasons  I  have  given  I  now  remove  the  descending  colon  and  a  por- 
tion or  the  whole  of  the  sigmoid,  closing  the  large  bowel  at,  or  just  above, 
its  junction  with  the  rectum. 

"The  termination  of  the  ileum  and  the  sigmoid  or  rectum  adjacent  to  it 
are  brought  into  convenient  opposition,  and  a  perfectly  secure  and  reliable 
lateral  anastomosis  is  made  by  means  of  a  double  row  of  continuous  sutures, 
the  inner  row  of  which  perforates  all  the  coats,  while  the  outer  does  not 
enter  the  lumen  of  the  bowel. 

"If  the  surgeon  prefers  it,  the  ileum  and  rectum  may  be  united  end-to- 
end.  This  is  the  ideal  way,  since  any  tendency  to  pouching  which  exists  in 
the  case  of  lateral  anastomosis  is  avoided.  The  objections  to  it  is  that  it  is 
not  so  safe  because  of  the  difference  in  the  circumference  of  the  two  pieces  of 
bowel, 'the  frequent  very  great  tenuity  of  the  wall  of  the  ileum,  and  the  diffi- 
culty occasionally  met  with  in  dealing  with  the  mesenteric  attachment. 

"Subsequent  dilatation  of  the  ileum  beyond  the  seat  of  lateral  anastom- 
osis may  be  avoided  by  sewing  down  and  obliterating  the  lumen  of  the  distal 
gut  right  up  to  the  aperture  of  communication  with  the  large  bowel. 

"Finally,  a  fine  gut  ligature  is  passed  through  the  free  incised  margin 
of  the  mesentery  of  the  ileum,  and  then  beneath  the  peritoneum  forming  the 
outer  wall  of  the  meso-rectum.  This,  when  made  tight,  brings  the  rectum 
to  the  middle  line  of  the  pelvis  and  fixes  it  securely  in  that  situation  imme- 
diately beneath  the  position  occupied  normally  by  the  divided  end  of  the 
ileum.  The  ligature  also  closes  the  interval  between  these  two  mesenteries, 
through  which  a  loop  of  bowel  might  otherwise  pass  and  give  trouble. 

"There  are  many  cases  in  which  the  patient  is  unable  to  sustain  the 
strain  of  the  removal  of  the  large  bowel,  but  can  that  of  division  of  the 
small  bowel  and  the  establishment  of  a  connection  between  it  and  the  sig- 
moid or  rectum.  This  operation  relieves  the  patient  of  the  toxemia. 

"Should  the  symptoms  resulting  from  the  distension  of  the  colon  cause 
sufficient  trouble  the  large  bowel  can  be  removed  at  a  later  date  with  much 
less  risk. 

"Again,  there  are  a  number  of  cases  of  extreme  toxemia,  who  have  no 
pain,  and  in  whom  the  division  of  the  ileum  and  its  connection  with  the  end 
of  the  large  bowel  is  sufficient,  since  it  relieves  the  patient  of  all  trouble. 

"The  stomach  is  exposed  and  is  usually  found  to  be  dilated  to  a  varying 
extent.  In  this  condition  the  pylorus  is  hung  up  by  adhesions  to  the  liver 
and  gall-bladder.  These  are  freely  divided.  I  have  employed  gold  leaf  to 
obviate  the  re-formation  of  adhesions  with  apparent  advantage.  The  ad- 
hesions tend  to  re-form  since  the  mechanical  factors  determining  their  devel- 
opment continue  to  exist.  When  the  weight  of  the  transverse  colon  has 


364  GENERAL    SURGERY    OF    THE    ABDOMEN 

been  removed,  during  the  period  of  recumbency  following  on  the  operation, 
the  dilatation  of  the  stomach  usually  disappears  more  or  less  completely.  On 
several  occasions  after  a  varying  interval  from  the  operation  of  resection  of 
the  large  bowel,  the  dilatation  of  the  stomach  has  become  a  feature  of  suffi- 
cient importance  to  require  its  more  effective  drainage  by  a  gastro-enter- 
ostomy.  This  operation  has  afforded  complete  relief  of  the  gastric  symp- 
toms. I  have  seen  cases  of  chronic  intestinal  stasis  in  which  a  gastro-enter- 
ostomy  alone  had  been  done  for  dilatation  of  the  stomach  with  very  distinct 
disadvantage  to  the  patient.  The  surgeon  has  not  recognized  the  sequence 
and  he  has  brought  the  operation  of  gastro-enterostomy  into  disrepute.  In- 
deed, I  have  seen  it  frequently  stated  that  gastro-enterostomy  is  of  no  service 
unless  there  be  obstruction  to  the  pylorus  by  growth  or  cicatrix.  To  attempt 
to  relieve  symptoms  by  performing  a  gastro-enterostomy  in  the  first  instance 
in  the  dilatation  of  the  stomach  that  follows  upon  chronic  intestinal  stasis 
is  of  little  or  no  avail." 

CARCINOMA  IN  THE  UPPER  PORTION  OF  THE  RECTUM. 

If  a  carcinoma  is  located  in  the  upper  portion  of  the  rectum  it  is  often 
impossible  to  approach  it  from  below,  but  it  can  be  removed  with  ease  through 
an  abdominal  incision.  This  operation  is  indicated  only  if  the  tumor  is  con- 
fined entirely  to  the  intestine,  because  if  the  surrounding  tissues  have  been 
invaded  the  removal  of  the  tumor  would  in  no  way  retard  the  progress  of 
the  disease. 

Technique. 

Under  favorable  conditions,  then,  the  following  operation  is  indicated : 
The  patient  is  placed  in  the  exaggerated  Trendelenburg  position.  An  in- 
cision is  made  through  the  linea  alba  extending  from  the  pubis  to  a  point  an 
inch  below  the  umbilicus.  The  intestines  are  held  away  by  means  of  moist 
gauze  tampons.  The  sigmoid  flexure  is  then  found  and  grasped  between 
two  pairs  of  long- jawed  pressure  forceps  placed  side  by  side  at  a  sufficient 
distance  above  the  tumor  to  make  sure  that  every  portion  of  the  growth  is 
several  inches  below  the  lower  pair  of  forceps.  The  intestine  is  then  severed 
between  these  two  pairs  of  forceps  and  a  second  incision  is  made  in  the  left 
inguinal  region,  corresponding  to  McBurney's  incision  for  the  removal  of  the 
vermiform  appendix  only  upon  the  opposite  side,  care  being  taken  to  separate 
the  fibers  of  the  external  and  internal  oblique  abdominal  muscles,  as  de- 
scribed in  the  previous  operation.  A  pair  of  long-jawed  pressure  forceps 
is  then  passed  through  this  opening  and  attached  to  the  upper  segment, 
which  is  withdrawn  through  this  wound  and  carefully  sutured  to  its  edges, 
after  a  large  rubber  tube  surrounding  a  glass  cylinder  has  been  inserted  in 
this  segment  and  fastened  in  place  by  means  of  a  purse-string  suture.  This 
will  permit  the  escape  of  gas  and  feces  without  any  danger  of  soiling  the 
abdominal  wound.  The  pair  of  forceps  upon  the  lower  segment  is  lifted 
toward  the  abdominal  incision  and  the  posterior  attachment  of  the  intestine 
below  these  forceps  is  successively  grasped  by  means  of  pressure  forceps, 
and  as  the  attachment  is  grasped  the  intestine  is  cut  loose.  In  this  manner 
the  entire  intestine  can  be  loosened  without  the  slightest  danger  of  hem- 
orrhage. If  the  diseased  portion  is  not  extensive  two  other  pairs  of  pressure 
forceps  are  placed  parallel  to  each  other  at  a  sufficient  distance  below  the 
:umor  to  insure  its  complete  removal.  The  intestine  is  cut  off  between  these 


PLATE  XLI. 
Profile  drawing  of  median  section  of  the  pelvis,  showing  completed  anastomosis. 


GENERAL    SURGERY    OF    THE    ABDOMEN  367 

two  forceps  and  the  tumor  removed,  together  with  the  forceps  above 
and  below  it.  A  purse-string  stitch  is  applied  around  the  lower  segment,  and 
the  edges  caught  by  means  of  the  pressure  forceps  are  inverted.  Then  the 
entire  abraded  surface  is  covered  with  peritoneum  and  the  abdominal  wound 
closed.  Occasionally  the  sigmoid  flexure  is  so  long  and  its  attachments  so 
loose  that  it  is  possible  to  withdraw  the  upper  segment  through  the  lower 
segment  and  treat  according  to  the  method  introduced  by  Gibson,  which 
has  already  been  fully  described. 

At  this  point  we  wish  to  emphasize  the  fact  that  it  is  most  important  to 
make  a  free  excision  of  these  tumors,  and  that  in  no  case  should  one  make 
a  less  thorough  operation  for  the  sake  of  maintaining  the  natural  instead 
of  the  artificial  anus. 

INTESTINAL  FISTULA. 
Causes  and  Incidence. 

Intestinal  fistulas  at  the  present  time  occur  most  frequently  after  oper- 
ations performed  for  the  relief  of  acute  appendicitis  complicated  by  the 
formation  of  extensive  abscesses.  The  fistulas  are  more  common  in  cases 
in  which  the  appendix  itself  has  not  been  removed,  or  in  which  the  appendix 
has  been  removed  at  an  inappropriate  time  or  with  extreme  manipulations. 
The  condition  also  occurs  after  other  operations  in  which  the  intestinal  wall 
nas  been  injured  either  by  disease  or  by  the  operation,  or  by  the  drainage 
tube  which  was  applied  after  operation.  It  is  more  common  after  opera- 
tions which  have  been  performed  for  the  relief  of  inflammatory  conditions, 
such  as  pyosalpinx.  It  also  occurs  after  operations  for  strangulated  hernia 
and  after  those  for  the  resection  of  any  portion  of  the  intestinal  tract.  After 
operations  for  the  relief  of  tubercular  peritonitis,  in  which  the  adhesions 
between  loops  of  intestines  have  been  separated,  intestinal  fistulse  frequently 
occur;  they  also  follow  direct  injury  to  the  intestinal  tract. 

Spontaneous  Cure. 

A  considerable  proportion  of  intestinal  fistulas  will  heal  if  absolute  rest 
is  secured  as  nearly  as  possible.  This  may  be  accomplished  most  readily  by 
first  emptying  the  alimentary  canal  thoroughly  by  means  of  large,  repeated 
doses  of  castor  oil,  which  will  remove  not  only  the  food,  but  also  all  mucus 
contained  in  the  canal.  The  fistulse  should  be  thoroughly  cleansed  by  irriga- 
tion. This  should  be  followed  by  feeding  the  patient  exclusively  by  means 
of  nutrient  enemata.  In  this  manner  the  intestinal  canal  may  be  kept  rela- 
tively empty  for  a  number  of  days,  and  in  the  meantime  the  openings  in  the 
intestine  are  likely  to  decrease  in  size  unless  there  is  a  marked  eversion  of 
the  mucous  membrane.  If  this  condition  is  present  nothing  but  a  radical 
operation  will  bring  relief.  The  same  is  true  if  there  is  a  stricture  or  nar- 
rowing of  the  intestinal  canal  distal  to  the  fistula.  Occasionally  this  will 
prevent  the  healing  of  an  intestinal  fistula  which  would  otherwise  respond 
readily  to  treatment. 
Operative  Technique. 

It  is  usually  wise  to  postpone  the  operation  until  the  course  above  de- 
scribed has  been  thoroughly  tried,  because  one  will  frequently  succeed  by 
the  simpler  method  even  after  the  fistula  has  existed  for  a  considerable  time, 
and  this  is  especially  true  of  fistulre  in  portions  of  the  colon  where  the  bowel 
is  covered  with  peritoneum. 


GENERAL    SURGERY    OF    THE    ABDOMEN 

The  incision  through  the  abdominal  wall  should  be  made  at  some  dis- 
tance from  the  fistula  so  as  to  avoid  the  adhesions  which  one  is  sure  to 
encounter  at  the  point  where  the  abdominal  wall  is  penetrated  by  the  fistula. 
The  amount  of  traumatism  necessary  for  performing  the  operation  required 
is  very  much  reduced  if  this  precaution  is  taken,  because  the  conditions  may 
be  determined  much  more  perfectly  if  the  abdominal  cavity  is  opened  at  a 
point  quite  away  from  these  adhesions.  The  incision  should  be  sufficiently 
long  to  permit  of  performing  the  entire  operation  in  full  sight. 

After  the  abdominal  cavity  has  been  opened  all  of  the  intra-abdominal 
organs  should  be  tamponed  away  from  the  portion  of  the  intestines  involved, 
then  these  should  be  loosened  from  the  abdominal  wall  and  carefully  brought 
out  so  that  all  abrasions  upon  their  surfaces  may  be  carefully  repaired.  At- 
tention is  then  given  to  the  fistula  itself.  In  cases  following  appendicitis 
operation  the  fistula  most  frequently  enters  the  appendix  at  the  point  at 
which  that  organ  was  perforated  during  the  acute  attack.  All  that  needs  to 
be  done  in  such  instance  is  to  remove  the  entire  appendix  after  the  methods 
described  heretofore.  In  these  cases  the  method  of  separating  the  appendix 
first  from  its  cecal  end  and  then  dissecting  it  out  distally  is  especially  useful. 
It  may  be  dissected  out  together  with  the  fistula.  The  abraded  surfaces  upon 
the  intestines  which  have  been  adherent  must  be  carefully  covered  with 
peritoneum.  It  is  usually  well  to  pass  a  drain  through  the  opening  in  the 
abdominal  wall  through  which  the  fistula  extended  down  to  the  seat  of  injury 
in  the  intestine,  and  then  to  completely  close  the  new  opening  in  the  abdom- 
inal wall.  If  the  fistula  is  in  the  cecum  it  is  usually  not  difficult  to  close  it  by 
means  of  sutures  if  the  following  points  are  borne  in  mind : 

i  st.     The  tissues  to  be  sutured  must  not  be  cicatricial  in  character. 

2nd.  The  sutures  must  be  applied  with  great  accuracy  so  as  to  have  a 
perfect  coaptation  of  surfaces. 

3d.     The  sutures  must  not  grasp  too  large  an  amount  of  tissue. 

4th.  The  entire  line  of  sutures  when  completed  must  be  covered  with 
healthy  peritoneum  or  with  a  piece  of  omentum. 

A  drain  should  be  placed  down  to  the  point  of  suture  as  described  above. 

In  fistulse  of  the  small  intestines  it  is  usually  advisable  to  make  a  resec- 
tion of  a  considerable  portion  of  the  bowel,  in  fact,  a  sufficient  amount  should 
be  removed  to  make  the  anastomosis  between  the  ends  in  entirely  healthy 
tissue.  This  can  then  be  accomplished  by  means  of  the  Murphy  button,  as 
described  before ;  or  by  means  of  the  continuous  or  interrupted  intestinal 
suture,  also  described ;  or  the  ends  of  the  intestine  may  be  closed  and  a  lateral 
anastomosis  may  be  made  after  the  method  already  outlined,  which  is  the 
safest,  as  a  rule.  In  any  event  the  important  point  to  be  borne  in  mind  is 
that  the  operation  must  be  done  entirely  in  healthy  tissue.  The  loss  of  a 
number  of  feet  of  small  intestine  is  of  practically  no  importance  to  the 
patient,  but  if  too  little  is  taken  away  for  the  sake  of  saving  a  small  portion 
of  intestine  a  subsequent  perforation  is  liable  to  occur. 

Fistulse  following  operations  for  the  relief  of  tubercular  peritonitis  can 
usually  be  healed  only  if  the  tuberculosis  affects  but  a  relatively  small  por- 
tion of  the  intestine  which  can  be  removed  in  toto.  In  this  case  the  same 
conditions  obtain  which  have  just  been  described.  If  the  tuberculosis  is  not 
relatively  circumscribed  then  these  fistulce  can  virtually  never  be  cured. 

Occasionally  an  intestinal  fistula  is  complicated  by  such  extensive  ad- 
hesions that  it  seems  unsafe  to  loosen  them,  and  it  then  may  become  neces- 
sary to  make  a  lateral  anastomosis  between  the  intestine  going  toward  the 


A.Co\it* 


A  Colica   c*<t>6  J 


A.lUo 


Fig.  16. 
Carcinoma  of  cecum.     Dotted  lines  showing  lines  of  resection.      (Mayo.) 


GENERAL    SURGERY    OF    THE    ABDOMEN  371 

fistula  and  that  coming  from  it  in  order  to  short-circuit  the  gut  at  this  point. 
It  is  best  to  pass  a  silk  purse-string  suture  about  the  portion  of  bowel  to  be 
eliminated  just  beyond  the  anastomosis,  in  order  to  prevent  intestinal  con- 
tents from  entering  this  portion.  The  suture  should  be  applied  subperi- 
toneally  and  tied  just  tightly  enough  to  accomplish  this  end  without  causing 
pressure  necrosis. 

INTUSSUSCEPTION. 

This  is  encountered  usually  in  very  small  children  although  it  occurs 
occasionally  in  children  ten  years  of  age  or  even  older,  and  it  may  happen 
in  the  adult,  but  so  rarely  that  we  have  never  seen  such  an  instance.  Our 
eldest  patient  was  not  more  than  twelve  years  of  age,  while  we  have  treated 
many  children  between  one  and  four  years  of  age. 

Typical  Case. 

The  child  is  sixteen  months  of  age  and  had  been  perfectly  well  until  six 
hours  ago  when  she  suddenly  began  to  complain  of  severe  colicky  pain  in 
the  abdomen.  She  desired  to  evacuate  her  bowels  but  was  unsuccessful. 
Half  an  hour  later  a  second  attempt  was  unsuccessful  and  an  enema  which 
was  given  in  the  hope  of  relieving  the  condition  came  away  clear,  although 
a  slight  amount  of  mucus  was  expelled  directly  after.  From  this  time  on 
the  patient  has  had  repeated  attacks  of  pain,  very  severe,  causing  the  child 
to  cry  out  and  draw  its  thighs  upon  its  abdomen. 

The  family  physician,  who  was  called,  gave  an  enema  and  a  mild  seda- 
tive and  advised  the  use  of  calomel  later  on  in  case  relief  should  not  come. 
A  second  physician  was  called  and  applied  hot  fomentations  to  the  abdomen 
and  recommended  consulting  a  surgeon  later.  The  pain  becoming  constantly 
more  severe  and  the  parents  having  had  experience  the  previous  year  with 
a  case  of  acute  perforative  appendicitis  in  a  child  two  years  older,  the  con- 
sultation was  arranged  for  promptly. 

Present  Condition. 

The  child  being  undressed  we  find  a  well-nourished,  perfectly  healthy 
appearance,  with  excellent  color  and  well  formed  body.  Lungs  and  heart  are 
normal.  While  inspecting  the  abdomen  a  bulging  appears  opposite  the 
middle  of  the  right  rectus  abdominis  muscle,  at  the  same  time  the  child 
draws  its  thighs  up  over  the  abdomen  and  begins  to  cry,  evidently  because 
of  severe  intra-abdominal  pain. 

All  of  these  symptoms  subside  in  about  two  minutes.  Palpatation  of 
the  abdomen  reveals  a  hard  sausage-like  body  to  the  right  and  a  little  above 
the  umbilicus  in  the  region  normally  occupied  by  the  hepatic  flexure  of  the 
colon.  The  abdominal  muscles  over  this  mass  are  somewhat  tense.  Nothing 
else  abnormal  can  be  discovered.  Some  mucus  which  has  been  expelled  is 
slightly  streaked  with  blood.  Upon  again  questioning  the  nurse  the  fact 
that  the  child  fell  from  a  foot-stool  upon  the  carpet  early  in  the  afternoon 
was  elicited,  but  as  the  child  had  arisen  at  once  and  had  not  complained  the 
matter  had  not  impressed  itself  upon  the  maid  until  she  was  questioned  spe- 
cifically. The  child  had  taken  a  little  water  since  the  time  of  the  fall  but  no 
food. 

The  second  physician  had  made  a  diagnosis  of  intussusception  which  we 
confirmed  at  once  upon  making  the  examination  just  described.  The  child 
was  brought  to  the  hospital  at  once  and  we  will  make  an  abdominal  section 


372  GENERAL    SURGERY    OF    THE    ABDOMEN 

without  any  delay,  because  all  of  these  cases  operated  within  the  first  twenty- 
four  hours  after  the  beginning  of  the  attack  have  made  a  perfect  recovery, 
while  those  in  whom  the  operation  had  been  delayed  longer  showed  much 
less  favorable  results. 

The  patient  will  be  immediately  anesthetized  with  ether,  then  the  skin 
covering  the  abdomen  will  be  disinfected  in  the  usual  manner  and  then  we 
will  split  the  right  rectus  abdominis  muscle  longitudinally  at  a  point  opposite 
the  umbilicus  by  an  incision  fifteen  cm.  long,  dividing  the  muscle  as  nearly 
as  possible  into  halves.  It  is  best  to  make  the  incision  sufficiently  long  to 
prevent  trauma  to  the  intestine  during  the  subsequent  manipulations. 

The  cecum,  a  portion  of  the  ileum  and  the  vermiform  appendix  have 
been  telescoped  into  the  transverse  colon.  Seeing  this  mass  before  you  there 
is  temptation  to  seize  the  ileum  and  make  traction  upon  it  for  the  purpose  of 
reducing  the  intussusception.  Experience  has  shown,  however,  that  such  a 
course  is  not  proper,  because  it  seems  to  wedge  the  inner  intestine  more 
tightly  to  the  outer  one ;  while  by  pressing  upon  the  outer  surface  of  the 
colon  just  beyond  the  point  to  which  the  inner  gut  reaches  the  latter  may  be 
readily  pushed  back  until  the  whole  length  of  intestine  is  again  free.  A 
careful  inspection  of  the  cecum,  transverse  colon  and  ileum  shows  that  no 
necrosis  and  no  abrasion  has  taken  place.  Had  the  intussusception  remained 
for  twenty-four  hours  or  longer  some  points  of  gangrene  and  some  areas 
of  abrasions  would  surely  be  discovered.  Still  later  a  large  portion  of  the 
intestine  becomes  gangrenous.  Occasionally  such  a  gangrenous  intestine  will 
slough  away  entirely  and  be  expelled  through  the  rectum,  the  two  portions 
beyond  this  segment  uniting  spontaneously,  but  much  more  frequently  the 
condition  results  in  a  fatal  peritonitis. 

Upon  inspecting  the  vermiform  appendix  we  find  that  it  is  fourteen  cm. 
long  and  that  it  forms  a  constricting  band  around  the  ileum  just  outside  of 
the  ileo-cecal  junction.  It  is  likely  that  when  the  child  had  its  fall  the  ap- 
pendix was  thrown  around  the  ileum  in  this  abnormal  position  and  that  the 
constriction  caused  by  the  appendix  at  this  point  was  the  exciting  cause  which 
produced  the  imagination. 

\Ye  will  remove  the  appendix  in  the  usual  manner  and  close  the  abdom- 
inal wound. 

During  the  entire  operation  there  has  been  but  very  little  manipulation 
of  the  intra-abdominal  organs,  and  it  seems  reasonable  to  expect  that  this 
patient  will  recover  without  shock  or  sepsis. 

After  Treatment. 

The  patient  will  be  kept  quiet,  she  will  be  nourished  for  four  days  by 
nutrient  enemata.  then  broth  will  be  given  by  month.  Small  cleansing 
enemata  will  be  employed  to  evacuate  the  bowel.  Xo  cathartics  will  be  al- 
lowed for  one  month.  Only  such  food  will  be  given  as  can  be  easily  digested 
without  producing  much  residue. 

In  cases  that  come  under  surgical  treatment  later,  after  the  intestine  has 
become  gangrenous,  it  is  best  to  excise  all  of  the  bowel  involved  in  the 
intussusception,  after  the  method  described  for  excision  of  the  colon  with  a 
part  of  the  ileum. 

Frequently  by  first  making  an  attempt  at  reduction  of  the  intussuscep- 
tion in  late  cases  the  peritoneum  is  so  severely  infected  that  the  patient  dies 
of  diffuse  peritonitis,  while  he  would  surely  have  recovered  had  these  useless 
manipulations  been  omitted. 


GENERAL    SURGERY    OF    THE    ABDOMEN  373 

In  making  this  excision  it  is  well  to  remember  that  it  is  even  more  likely 
to  injure  the  duodenum  in  this  operation  than  in  the  simple  excision  of  the 
ascending  colon,  but  if  the  surgeon's  attention  has  been  directed  to  the  fact 
it  is  not  difficult  to  avoid  this  complication. 

VOLVULUS. 

Another  common  condition,  which,  like  intussusception,  is  characterized 
by  intestinal  obstruction,  consists  of  a  twisting  of  the  small  intestine,  the 
sigmoid  flexure  of  the  colon,  or,  much  more  rarely,  the  transverse  colon  upon 
its  mesentery,  thus  at  once  obstructing  the  passage  and  destroying  the  cir- 
culation. The  twisting  of  the  mesentery  gives  rise  to  severe  pain. 

The  closure  of  the  intestine  causes  nausea  and  vomiting,  the  vomitus 
consisting  at  first  of  stomach  contents,  then  mucus  and  bile,  and  later  more 
or  less  decomposed  intestinal  contents. 

The  vomiting  appears  early  when  the  volvulus  occurs  in  the  jejunum, 
later  when  in  the  ileum,  and  quite  late  when  in  the  colon. 

The  condition  is  frequently  preceded  by  a  slight  fall  or  by  excessive 
lifting  or  straining.  Occasionally  it  may  be  mistaken  for  an  acute  gastric 
disturbance,  because  of  taking  some  indigestible  food,  and  a  few  times  we 
have  observed  patients  who  imagined  that  they  had  taken  spoiled  food  and 
that  they  were  suffering  from  ptomain  poisoning. 

Four  times  we  have  had  patients  sent  to  the  hospital  with  a  diagnosis 
of  volvulus  in  whom  we  found  the  obstruction  due  to  a  small  hernia  which 
had  not  previously  been  recognized.  The  fact  that  the  condition  had  come  on 
suddenly  after  a  slight  exertion  had  given  rise  to  the  mistaken  diagnosis. 
In  a  fifth  case  the  hernia  was  so  slight  that  it  was  not  discovered  until  it 
was  located  after  the  abdomen  had  been  opened,  when  a  small  portion  of 
one  side  of  the  small  intestine  was  found  caught  in  the  femoral  ring,  the 
obstruction  being  due  to  the  kinking  of  the  intestine. 

Although  it  is  not  always  possible  to  make  a  differential  diagnosis  be- 
tween volvulus  and  acute  intestinal  obstruction  from  other  causes  it  is  pos- 
sible in  these  cases  to  determine  the  presence  of  a  mechanical  obstruction 
to  the  intestines  and  it  does  not  matter  what  may  be  the  cause  of  this  condi- 
tion as  the  indication  for  treatment  is  always  the  same. 

ACUTE  MECHANICAL  OBSTRUCTION  OF  THE  INTESTINE. 

Before  speaking  of  the  special  treatment  for  volvulus  it  may  be  well 
to  discuss  the  treatment  of  acute  intestinal  obstruction,  which  applies  to  this 
condition  without  regard  to  the  mechanical  condition  which  gives  rise  to 
obstruction  in  any  given  case. 

A  statement  which  should  be  repeated  many  times  and  always  regarded 
when  any  form  of  intestinal  obstruction  is  considered,  and  even  when  there 
is  the  slightest  suspicion  of  the  possibility  of  the  existence  of  intestinal  ob- 
struction in  any  given  case,  is  that  it  is  absolutely  unpardonable  to  give  either 
cathartics  or  any  form  of  nourishment  by  mouth.  In  our  experience  the 
mortality  has  been  ten  times  higher  in  patients  who  had  been  given  cathartics 
before  coming  into  the  hospital  suffering  from  intestinal  obstruction,  than 
in  those  who  had  received  none. 

It  is  so  absolutely  clear  that  if  no  food  be  administered  by  mouth  any 
case  in  which  there  is  no  mechanical  obstruction  of  the  bowels  does  not 


374  GENERAL    SURGERY    OF    THE    ABDOMEN 

need  a  cathartic  because  the  bowels  will  move  spontaneously  if  given  time 
and  proctoclysis  by  the  continuous  drop  method,  while  if  mechanical  ob- 
struction is  present  the  giving  of  cathartics  will  almost  certainly  kill  the 
patient.  In  other  words  in  order  to  prove  that  a  certain  number  of  patients 
do  not  have  a  mechanical  obstruction  of  the  intestines  one  takes  the  risk,  by 
using  cathartics,  of  destroying  the  lives  of  almost  all  of  those  who  are 
actually  suffering  from  this  condition. 

The  reason  why  it  is  so  dangerous  to  give  cathartics  in  these  cases  is 
because  they  enormously  increase  the  pressure  above  the  point  of  obstruc- 
tion, and  consequently  the  intestine  is  made  more  permeable  to  micro-organ- 
isms in  its  lumen  and  the  increased  pressure  hastens  the  occurrence  of  gan- 
grene of  the  intestine  at  the  point  of  obstruction. 

As  harmful  as  is  the  giving  of  food  and  cathartics  in  these  cases,  so 
beneficial  is  the  opposite  form  of  treatment  by  means  of  repeated  gastric 
lavage,  which  removes  a  great  .amount  of  poisonous  material  from  the 
alimentary  canal  and  permits  the  intestines  and  the  stomach  to  contract. 
It  also  prevents  the  occurrence  of  inspiration  pneumonia  caused  by  the  pres- 
ence of  fetid  intestinal  contents  during  the  operation. 

When  in  doubt  in  these  cases  a  competent  surgeon  should  operate,  al- 
though by  carefully  taking  the  history  and  examining  these  patients  an 
experienced  surgeon  can  almost  always  make  a  positive  diagnosis. 

On  the  other  hand  an  inexperienced  surgeon  who  is  in  doubt  should 
continue  denying  absolutely  everything  by  mouth,  should  employ  gastric 
lavage  and  administer  normal  salt  solution  by  rectum  by  the  continuous  drop 
method  until  the  patient  can  be  gotten  into  the  hands  of  a  competent  surgeon. 

Operative    Technique. 

When  it  is  possible  to  locate  the  twisted  loop  of  intestine  by  the  bulging 
<>f  some  portion  of  the  abdominal  wall,  or  by  auscultation  (the  intestinal 
fluid  moving  up  to  a  given  point  and  stopping  at  such  point),  or  by  the 
accurate  location  of  pain  or  tenderness,  it  is  well  to  make  the  incision  either 
in  the  median  line  or  by  splitting  either  rectus  abdominis  muscle  longitud- 
inally directly  over  the  affected  part. 

Should  the  location  or  the  character  of  the  obstruction,  or  both,  not  be 
positively  demonstrated  before  the  abdomen  is  opened  it  is  best  to  make  a 
median  incision  if  the  appendix,  the  gall  bladder  or  the  duodenum  are  prob- 
ably not  the  seat  of  the  trouble;  otherwise  an  incision  splitting  the  right 
rectus  abdominis  muscle  probably  gives  the  best  approach  to  the  diseased 
part  because  the  location  of  this  condition  is  twice  as  frequent  in  the  right 
as  in  the  left  half  of  the  abdominal  cavity. 

If  the  intestines  are  greatly  dilated  and  the  patient  is  in  a  fair  condition 
the  gas  and  feces  should  be  first  evacuated  by  emptying  a  small  portion  of 
the  most  prominent  loop  of  the  intestine  by  squeezing  the  contents  in  either 
direction,  then  having  an  assistant  hold  this  empty  portion  between  the  finger 
and  thumb  of  each  hand,  thus  preventing  its  refilling.  A  circular  silk  suture 
is  then  applied  at  a  point  farthest  away  from  the  mesenteric  attachment  of 
the  intestine,  then  a  longitudinal  slit  is  made  into  the  lumen  of  the  intestine 
two  cm.  long.  A  glass  tube  two  cm.  in  diameter,  with  smooth  ends,  and 
sixty  cm.  long  is  inserted  into  this  opening  and  the  edges  of  the  wound  are 
inverted  and  the  suture  is  tied  in  a  loop  so  that  it  can  be  untied  later  on. 
Then  the  assistant  relinquishes  his  grasp  upon  the  intestine  and  its  contents 
are  permitted  to  pass  out  through  the  glass  tube.  It  is  usually  impossible  to 


GENERAL    SURGERY    OF    THE    ABDOMEN  375 

push  this;  tube  into  the  intestines,  as  demonstrated  experimentally  by  Monks, 
but  the  intestine  can  be  threaded  upon  the  tube  successively  until  all  of  the 
gas  and  feces  have  escaped.  The  intestine  is  filled  and  emptied  several  times 
with  normal  salt  solution  at  100  to  105  degrees  F.  Then  the  tube  is  with- 
drawn slowly  and  this  portion  of  the  intestine  is  again  grasped  by  the  as- 
sistant in  order  to  prevent  its  refilling  and  the  glass  tube  is  threaded  into  the 
opposite  end,  which  is  emptied  and  washed  in  the  same  manner.  Then  the 
tube  is  withdrawn  and  the  wound  in  the  intestinal  wall  closed,  an  assistant 
compressing  the  bowel  at  either  side  to  prevent  leakage.  It  is  remarkable 
how  quickly  the  intestine  takes  on  a  normal  appearance  under  this  treat- 
ment, and  how  well  these  patients  bear  the  operation. 

After  the  above  procedures  it  is  possible  to  locate  the  volvulus,  because 
this  will  be  the  only  portion  of  the  intestine  that  remains  distended.  If  the 
intestine  is  gangrenous  or  if  the  mesenteric  vessels  are  thrombosed  its  ex- 
cision according  to  the  methods  already  described  is  indicated.  If  the  vol- 
vulus has  not  so  resulted  then  the  intestine  must  be  untwisted  and  if  there 
are  any  adhesions  they  must  be  clamped,  cut  and  ligated.  If  the  intestine 
contained  in  the  volvulus  is  of  considerable  length  and  not  gangrenous  it  is 
well  to  leave  the  glass  tube  in  place  and  to  evacuate  the  gas  and  fluid  con- 
tained in  this  loop  before  the  intestine  is  closed.  If  the  volvulus  includes 
the  sigmoid  flexure  or  the  descending  colon  it  is  well  to  pass  a  rubber  tube 
up  through  the  rectum  and  just  beyond  the  loop  involved  in  order  to  secure 
drainage  and  to  keep  the  loop  in  position  until  it  has  been  restored  from  the 
effects  of  the  torsion.  The  tube  should  be  composed  of  fairly  pliable  rubber 
to  prevent  injury  from  pressure.  It  is  well  to  have  the  tube  split  longitud- 
Minlly  to  facilitate  its  acting  as  a  drain. 

Should  the  patient's  condition  be  very  bad  it  may  be  best  simply  to 
mrke  an  enterostomy  by  bringing  up  a  distended  loop,  attaching  it  to  the 
parietal  peritoneum,  then  finding  the  volvulus,  untwisting  it,  and  leaving  it 
in  place.  This  operation  in  volvulus  is  so  seldom  followed  by  recovery  that 
in  almost  every  case  the  method  described  before  is  preferable. 

ACUTE     INTESTINAL     OBSTRUCTION         DUE     TO      CONSTRICTING 

BANDS  OF  ADHESIONS. 

Here  there  is  usually  a  history  of  a  previous  operation  or  of  peritonitis 
from  any  cause.  In  all  other  details  the  history  and  the  clinical  symptoms 
are  the  same  as  in  volvulus. 

The  treatment  is  the  same,  with  the  exception  that  the  location  of  the 
constricting  band  is  usually  in  the  vicinity  of  the  former  operation,  or  the 
former  peritonitis  the  origin  of  which  is  more  commonly  the  appendix  or 
the  Fallopian  tube,  than  from  any  other  points  in  the  abdominal  cavity,  al- 
though we  have  seen  three  cases  in  which  the  band  represented  a  remnant  of 
the  omphalomesenteric  duct. 

ACUTE  OBSTRUCTION  DUE  TO  KINKING  OF  INTESTINES. 

This  condition  can  but  rarely  be  differentiated  before  the  operation  from 
that  just  described  as  its  origin  and  entire  history  are  the  same,  and  the  treat- 
ment is  identical.  The  attacks  are  usually  somewhat  less  acute  and  less 
violent  and  the  obstruction  is  frequently  not  quite  complete. 


376  r.KNKKAI.    SUKGI-IUY    OK    'I  II K    AHDOMKN 

HERNIA. 
General  Considerations. 

The  most  common  anatomical  varieties  of  hernia,  in  order  of  their 
frequency  are:  I.  Inguinal.  2.  Umbilical.  3.  Femoral.  4.  Ventral.  5. 
Hernia  of  the  linea  alba. 

Among  the  rarer  forms  are :  Ischiatic,  Pelvic,  Obturator,  Lumbar, 
Diaphragmatic,  and  the  various  forms  of  retro-peritoneal  hernia,  as  retro- 
cecal,  duodenal,  hernia  through  the  foramen  of  Winslow. 

Clinically  hernias  are  classified  as  reducible,  irreducible,  inflamed  and 
strangulated. 

Reducible  hernia  is  by  far  the  most  common  of  all  varieties.  In  this 
form  the  hernial  contents  may  be  returned  into  the  abdominal  cavity  spon- 
taneously or  when  the  patient  assumes  the  recumbent  position,  or  by  manip- 
ulation by  the  patient  or  by  the  physician. 

In  the  early  stages  of  development  practically  all  hernias  are  reducible. 
Later  on,  from  the  constant  irritation,  in  a  considerable  proportion  of  cases, 
the  hernial  contents  become  adherent  to  the  sac  making  it  impossible  to  effect 
a  complete  reduction.  This  is  especially  apt  to  happen  in  cases  of  umbilical 
hernia. 

In  other  instances  the  hernial  sac  is  large  and  the  neck  of  the  sac  is 
comparatively  small,  so  that  considerable  effort  is  required  to  accomplish  the 
reduction.  In  many  cases  in  which  it  seems  almost  impossible  to  replace 
the  hernial  contents  when  the  patient  is  in  the  ordinary  recumbent  position, 
reduction  may  be  accomplished  with  ease  after  placing  the  patient  in  the 
Trendelenburg  position. 

The    Hernial   Sac. 

With  the  exception  of  some  of  the  rarer  forms  of  hernia,  such  as  dia- 
phragmatic and  the  retroperitoneal  forms,  there  is  one  feature  common  to 
all,  and  that  is  the  sac.  This  sac  is  composed  of  a  layer  of  peritoneum  which 
covers  either  a  portion  or  the  entire  contents  of  the  hernia.  The  sac  is 
originally  a  very  thin  membrane,  but  may  undergo  marked  changes  in  cases 
of  long  standing  and  in  those  in  which  an  ill-fitting  truss  has  been  worn  for 
a  long  time.  In  such  the  sac  may  become  markedly  thickened,  very  tough 
;.nd  of  leathery  consistence. 

Tn  the  congenital  form,  the  hernial  sac  is  a  preformed  pouch  of  peri- 
toneum which  remains  empty  until  some  unusual  effort  or  accident  causes  an 
increased  intra-abdominal  pressure,  which  forces  some  of  the  abdominal 
contents  into  this  pouch. 

Tn  the  acquired  variety  the  parietal  peritoneum  is  forced  by  intra-ab- 
dominal pressure  through  some  congenital  defect  in  the  abdominal  wall. 

In  oblique  inguinal  hernia  the  sac  always  bears  a  certain  relation  to 
the  spermatic  cord.  It  is  always  found  in  a  position  anterior  to  the  cord  and 
the  spermatic  vessels,  and  is  surrounded,  together  with  the  latter,  by  the  thin 
layer  of  infundibuliform  fascia.  In  inguinal  hernia  in  the  female  the  sac 
bears  the  same  relation  to  the  round  ligament  as  to  the  cord  in  the  male 
and  is  very  closely  attached  to  it. 

There  are  some  conditions  in  which  the  hernial  sac  may  be  incomplete, 
such  as  sliding  hernia  of  the  sigmoid.  cecum  and  occasionally  of  the  bladder. 
In  such  cases  the  anterior  portion  of  the  sac  is  formed  of  peritoneum  and 
the  posterior  portion  is  continuous  with  the  wall  of  the  sigmoid.  cecum  or 
bladder,  whichever  one  may  be  involved.  Clinically  it  is  important  to  bear 


PLATE  XLII. 

A.  External  Oblique.     B.  Internal  Oblique.     C.  Transversalis 
ment.     E.  Internal  Abdominal  Ring.     F.  Epigastric  Artery.     G. 
H.  Below  this  point  is  the  External  Abdominal  Ring. 


.     D.  Poupart's  Liga- 
Transversalis  Fascia. 


PLATE  XLIII. 
FERGUSON'S  HERNIOTOMV. 

Deep  chromicized  catgut  sutures  in  place,  a  fascia  of  external  oblique  ab- 
dominal muscle;  b  Poupart's  ligament:  c  conjoined  tendon;  d  internal  oblique 
abdominal  muscle;  c  spermatic  cord  left  undisturbed  in  bottom  of  wound. 


GENERAL    SURGERY    OF    THE    ABDOMEN  381 

this  condition  in  mind,  in  order  not  to  injure  the  intestinal  wall  on  attempt- 
ing to  open  the  hernial  sac. 

In  direct  inguinal  hernia  in  the  male  the  hernia  descends  below  the 
epigastric  vessels  and  out  through  the  external  ring.  It  pushes  the  cord 
directly  in  front  of  it,  or  to  one  side,  but  does  not  bear  such  a  definite  and 
intimate  relation  to  the  cord  as  is  found  in  oblique  inguinal  hernia.  The  sac 
is  not  so  liable  to  descend  into  the  scrotum  as  in  oblique  inguinal  hernia,  but 
is  more  likely  to  take  an  outward  direction. 

The  size  and  shape  of  the  sac  in  inguinal  hernias  vary  greatly.  In 
scrotal  hernia  the  sac  is  most  often  pear-shaped. 

It  is  not  uncommon  to  find  a  constriction  at  about  the  center,  forming 
an  hour-glass  shaped  sac.  The  sac  is  also  frequently  sacculated,  and  occa- 
sionally to  such  an  extent  that  a  complete  double  sac  is  formed. 

The  contents  of  the  hernial  sac  also  varies  greatly.  Nearly  every  organ 
in  the  abdominal  cavity  has  been  found  to  form  a  part  or  the  whole  of  the 
contents  of  the  sac.  The  most  frequent  contents  are  the  omentum  and  small 
intestine,  and  then  some  portion  of  the  large  intestine,  and  next  the  bladder. 
In  femoral  hernia  the  intestine  rarely  forms  any  portion  of  the  contents 
except  in  cases  of  strangulation.  Various  portions  of  the  small  intestine 
may  be  caught  in  the  hernial  sac,  but  the  portion  most  frequently  involved  is 
a  loop  a  short  distance  above  the  ileo-cecal  valve,  which  has  a  longer  mesen- 
tery than  the  other  portions  of  the  small  intestine. 

The  edge  of  the  bladder  is  quite  frequently  found  in  the  sac  in  inguinal 
hernias  and  occasionally  a  diverticulum  or  pouch  of  the  bladder  forms  a 
considerable  part  of  the  sac  and  also  of  its  contents.  This  is  most  frequent 
in  patients  who  are  rather  obese  and  in  whom  there  is  a  diffuse  bulging  over 
the  inguinal  canal,  instead  of  having  a  pear-shaped  sac  descending  into  the 
scrotum. 

The  appendix  has  been  found  many  times  in  the  sac  of  inguinal  hernia, 
and  R.  E.  Webster  has  reported  a  case  of  strangulated  left  inguinal  hernia  in 
which  a  MeckePs  diverticulum  constituted  the  contents  of  the  sac. 

The  ovary  and  tube  together,  or  the  ovary  and  tube  separate,  have  fre- 
quently been  found  both  in  femoral  and  inguinal  hernias,  and  a  hernial  sac 
containing  the  uterus  has  been  reported  a  few  times. 

Etiology. 

Oblique  inguinal,  umbilical  and  femoral  hernia  occur  at  points  which  are 
naturally  weak  because  of  the  normal  opening  through  the  abdominal  wall 
during  fetal  life.  In  many  cases  of  oblique  inguinal,  and  in  some  of  the 
umbilical  variety,  these  openings  have  never  been  closed,  so  that  the  hernia 
is  in  consequence  congenital. 

The  theory  that  oblique  inguinal  hernia  is  primarily  always  due  to  an 
incomplete  closure  of  the  processus  vaginalis  testis  is  being  accepted  by 
many  surgeons.  This  is  due  largely  to  the  teachings  of  Mr.  Hamilton 
Russell,  of  Melbourne,  concerning  the  "saccular"  theory  for  the  etiology  of 
hernia.  In  accepting  this  theory,  it  does  not  mean  that  every  individual 
with  an  incompletely  obliterated  process  must  develop  a  hernia,  but  the  oc- 
currence depends  secondarily  upon  the  various  conditions  usually  enumer- 
ated as  the  exciting  and  predisposing  causes  of  hernia. 

Frequently  the  tissues  around  the  hernial  opening  are  much  weaker 
than  normal,  so  that  they  will  give  way  much  more  easily.  This  is  true  espe- 
cially in  patients  who  have  one  or  both  parents  with  a  similar  defect.  (More 


382  GENERAL    SURGERY    OF    THE    ABDOMEN 

than  one-third  of  all  patients  suffering  from  hernia  give  a  history  of  heredi- 
tary tendency  in  this  direction.) 

The  fact  that  the  spermatic  cord  passes  through  the  inguinal  canal 
makes  this  form  of  hernia  most  frequent.  A  long  omentum  with  its  ability 
to  become  insinuated  in  any  opening,  however  small  it  may  be,  is  a  common 
predisposing  cause  in  the  formation  of  hernia.  The  same  is  true  of  a  long 
mesentery. 

The  presence  of  a  great  quantity  of  fat  in  the  abdominal  wall  markedly 
weakens  this  structure,  first,  from  the  fact  that  lobes  of  fat  will  invade  the 
natural  openings  and  separate  the  connective  tissue  and  muscular  layers 
whose  function  it  is  to  prevent  the  formation  of  hernia ;  secondly,  because 
with  the  accumulation  of  great  quantities  of  fat  in  the  connective  tissue 
spaces  of  the  abdominal  wall  the  muscles  themselves  become  softened  on 
account  of  a  certain  amount  of  fatty  degeneration  which  takes  place  in  these 
tissues.  Moreover,  at  the  same  time  there  is  always  a  corresponding  increase 
in  the  amount  of  fat  within  the  abdominal  cavity,  which  not  only  favors  the 
formation  of  hernia  because  of  its  weight,  but  also  because  it  increases  the 
intra-abdominal  pressure. 

Exciting  Causes. 

The  chief  exciting  cause  is  increased  or  abnormal  intra-abdominal  pres- 
sure. This  may  be  very  violent  and  of  only  short  duration,  as  in  lifting 
heavy  weights,  falling  a  great  distance  or  with  very  great  force,  violent 
coughing  or  sneezing,  etc.  In  such  case  the  tissues  are  virtually  torn,  mak- 
ing an  opening  through  which  the  hernial  contents  protrude.  Again,  the 
abnormal  intra-abdominal  pressure  may  be  less  violent  and  more  continuous, 
as  where  there  is  a  long-continued  cough,  chronic  constipation,  or  an  ob- 
struction of  the  urethra  on  account  of  phimosis,  stricture,  enlargement  of 
the  prostate  gland  or  stone  in  the  bladder.  The  same  is  true  of  gaseous 
distension  of  the  stomach  and  intestines  due  to  digestive  disturbances.  Ad- 
hesions following  peritonitis  due  to  appendicitis,  or  infection  through  the 
Fallopian  tubes,  is  likely  to  have  the  same  effect.  In  short,  anything  which 
may  cause  abnormal  intra-abdominal  pressure,  either  acute  or  chronic,  is 
likely  to  bring  about  the  formation  of  a  hernia,  especially  if  there  is  a  pre- 
disposition thereto. 
General  Treatment. 

In  many  of  these  cases  a  properly-fitting  truss  will  secure  for  the  patient 
a  relative  degree  of  comfort  and  safety,  but  necessitates  the  wearing  of  an 
apparatus  which  is  at  best  unpleasant  and,  in  summer  especially,  annoying, 
uncomfortable,  fatiguing  and  sometimes  painful.  Aside  from  this  the  pa- 
tient is  constantly  exposed  to  the  risk  of  having  strangulation,  which  is, 
under  all  circumstances,  very  dangerous,  and  quite  a  considerable  pro- 
portion of  all  persons  suffering  from  hernia  lose  their  lives  sooner  or  later 
as  a  result  of  this  sequel.  Many  persons  suffering  from  hernia  find  it 
difficult  to  compete  with  others  of  their  rank  and  qualifications  because  of 
this  handicap. 

Pre-operative  Management. 

In  a  general  way  the  preparatory  treatment  is  the  same  for  these 
patients  as  for  those  about  to  undergo  any  other  serious  operation,  with 
the  addition,  it  may  be,  of  certain  steps  which  are  intended  to  eliminate 
as  much  as  possible  sonic  of  the  predisposing  causes. 


PLATE  XLTV. 
FERGUSON'S  OPERATION  FOR  INGUINAL  HERNIA. 

\\iih  deep  sutures  lied  uniting  im'.rna!  oblique  abdominal  and  transversa'is 
muscle  and  conjoined  tendon  to  Poupart's  ligament,  a  fascia  of  external  ob- 
lique abdominal  muscle;  c  conjoined  tendon:  d  internal  oblique  abdominal  mus- 
cle. The  untied  sutures  show  the  method  of  overlapping, — Andrews'  imbricatiofi 
principle  as  applied  to  Ferguson's  operation. 


PLATE  XLV. 

INGUINAL  HERNIA. 

Shows  the  anatomical  structures  exposed  by  the  primary  incision.  The  hernial 
sac  bulges  through  the  external  abdominal  ring  and  hides  the  tissues  of  the  spermatic 
cord.  The  fascia  of  the  external  oblique  abdominal  muscle  shows  a  point  of  weakness 
directly  over  the  inguinal  canal,  quite  common  in  inguinal  hernia. 

Taken  from  Professor  A.  H.  Ferguson's  original  drawings,  with  his  kind  per- 
mission. 


GENERAL    SURGERY    OF    THE    ABDOMEN  387 

It  is  well,  for  instance,  to  place  patients  who  have  a  great  accumu- 
lation of  fat  in  the  abdominal  wall  upon  a  systematic  course  of  treatment 
for  the  reduction  of  this  fat,  if  possible,  before  the  operation  is  per- 
formed. We  have  usually  employed  the  following  diet  with  excellent  re- 
sults, the  patient  losing  from  three  to  ten  pounds  per  week ;  the  general 
appearance  and  strength  improving  constantly  during  this  treatment.  Many 
have  lost  a  total  of  from  thirty  to  sixty  pounds  in  weight,  and  in  a  few 
very  obese  patients  the  loss  has  exceeded  one  hundred  pounds. 

The  diet  may  be  varied  to  suit  the  individual  case. 

DIET    LIST. 

Breakfast. — 

Tea — 4^oz. — A  very  small  cup. 

Milk — y$  oz. — One  and   a  half  tablespoons. 

Sugar — 75  grs. — A  small  lump. 

Bread — 375   grs. — A   very   small   slice, 

Dinner  — 

Sour  wine — 3^/3   oz. — A  wineglassful. 

One  egg,  or  lean  meat — 10  oz. 

Lettuce  with  vinegar — \2/^  oz. 

Vegetables — 1%  oz. 

Bread— 375  grs. 
Supper. — 

Wine — 1/2  pint. 

Water — ]/2-  pint. 

Quarter  small  chicken,  or  8  oz.  lean  meat. 

One  egg. 

Bread— 375  grs. 

These  meals  may  be  changed  about  to  suit  the  inclination  of  the  pa- 
tient. It  is  quite  as  well  to  take  the  food  prescribed  for  lunch  at  break- 
fast time,  and  t'icc  versa.  Men  who  are  in  business  frequently  find  the 
breakfast  insufficient,  and  the  bread  may  then  be  omitted  and  8  to  12  ounces 
of  lean  steak  substituted. 

Drink  nothing  during  the  meal,  nor  for  an  hour  before  or  after,  ex- 
cept as  given  in  the  above  list.  When  thirsty  during  the  day  drink  a  little 
sour  wine  or  sour  lemonade. 

Aside  from  this  the  patient  is  advised  to  walk  systematically,  begin- 
ning with  that  which  is  perfectly  comfortable  on  the  first  clay  and  increas- 
ing it  one-fourth  mile  daily  until  the  distance  reaches  from  six  to  twelve 
miles.  At  first  the  habitual  speed  of  walking  should  be  practised,  but  this 
should  be  increased  until  the  patient  covers  the  entire  distance  at  a  maxi- 
mum speed  for  his  strength.  During  this  walk  he  should  breathe  very 
deeply  through  the  nose,  the  lips  remaining  closed. 

Other  hygienic  measures  like  hot  baths  followed  bv  cold  shower,  mas- 
sage and  various  gymnastic  exercises  may  be  added  to  this  plan. 

All  this  will  not  only  reduce  the  amount  of  fat  in  the  abdominal  wall, 
but  also  to  a  great  extent  in  the  omentum  and  mesenterv  and  underneath 
the  peritoneum,  thus  reducing  the  intra-abdominal  pressure  to  a  marked 
degree,  and  at  the  same  time  increasing  the  firmness  of  all  the  tissues  in 
the  vicinity  of  the  hernia. 

If   there   is   an   abnormal    amount   of   intra-abdominal    pressure   due   to 


3oK  (iliNEKAL    SUKGKKY     OF    THE    ABDOMEN 

gaseous  distension  of  the  abdomen  caused  by  indigestion  this  should  be 
corrected.  The  same  is  true  of  constipation,  or  obstruction  to  the  passage 
of  urine,  or  a  chronic  bronchitis.  In  short,  so  far  as  possible,  it  is  wise 
to  eliminate  the  predisposing  causes  of  hernia  before  the  operation  for 
radical  cure  is  undertaken. 

The  same  rules  should  be  borne  in  mind  in  the  after-treatment.  Pro- 
vision should  be  made  against  the  recurrence  of  these  predisposing  causes 
after  the  patient  has  once  been  relieved  of  his  hernia  by  an  operation. 

INGUINAL  HERNIA. 
Typical  Case. 

Our  patient  is  thirty-eight  years  of  age  and  a  farm  laborer  by  occupa- 
tion. One  sister  died  at  eighteen  and  one  brother  at  twenty  years  of  age. 
His  mother  suffered  from  a  rupture.  Patient  had  whooping  cough  in 
childhood  and  typhoid  fever  at  eighteen  ;  was  weakly  and  ill  most  of  the 
time  until  the  age  of  twenty.  He  had  pneumonia  at  the  age  of  thirty-three. 
At  the  age  of  thirty  patient  felt  some  pain  in  both  inguinal  regions,  after 
climbing  a  tall  tree.  One  week  later  he  jumped  suddenly  out  of  bed,  when 
he  experienced  a  pain  in  the  left,  inguinal  region.  At  this  time  he  noticed 
a  small  bulging  over  the  left  inguinal  canal.  He  wore  a  truss  for  three 
years,  when  he  was  apparently  cured.  At  this  time  he  suffered  from  pneu- 
monia, coughed  a  great  deal,  and  when  he  had  recovered  from  this  sick- 
ness found  that  the  hernia  had  returned.  He  again  wore  a  truss,  which 
retained  the  hernia,  but  the  hernial  opening  showed  no  further  tendency 
toward  closing. 

Three  weeks  ago,  after  patient  had  been  working  hard  in  the  field,  he 
noticed  a  slight  bulging  on  the  right  side,  which  has  increased  constantly 
until  it  has  now  attained  the  size  of  a  hen's  egg.  Neither  hernia  has  caused 
pain.  There  has  been  no  tendency  towards  strangulation.  When  the  pa- 
tient is  in  a  recumbent  position  the  hernise  always  reduce  spontaneously. 

The  patient  is  fairly  well  nourished.  Lungs,  heart,  kidneys  and  ab- 
dominal organs  are  normal ;  the  tongue  is  slightly  coated ;  appetite  good  ; 
bowels  regular. 

The  abdomen  is  normal  except  for  a  marked  weakening  over  both  in- 
ternal abdominal  rings,  causing  a  bulging  the  size  of  a  hen's  egg  over  each 
inguinal  canal  when  the  patient  is  in  the  erect  position,  and  this  is  still  fur- 
ther exaggerated  upon  coughing.  The  enlargement  is  a  little  more  marked 
upon  the  right  side.  Patient  complains  of  a  feeling  of  weakness  at  this 
point  in  the  abdominal  wall  and  he  is  compelled  to  support  it  with  his  hand 
when  he  attempts  to  lift  any  weight.  The  right  inguinal  canal  easily  ad- 
mits the  tips  of  two  fingers;  the  left  the  tip  of  one  finger  only. 

The  contents  of  the  canal  can  be  easily  reduced  into  the  abdominal 
cavity  by  means  of  a  slight  amount  of  pressure,  and  upon  taking  the  re- 
cumbent position  the  bulging  disappears  at  once. 

All  of  the  conditions  are  so  clear  that  there  can  be  no  difficulty  in  mak- 
ing a  diagnosis  of  uncomplicated  double  inguinal  hernia. 

Differential   Diagnosis. 

Jt  is  almost  impossible-  to  make  a  wrong  diagnosis  in  simple  cases  of 
reducible  inguinal  hernia,  but  it  is  quite  different  if  some  complication  ex- 
ists. The  most  common  of  these  consist  of  adhesions.  If  some  of  the 
hernial  contents,  such  as  the  omentum  or  intestine,  are  adherent  to  the 


PLATE  XLYI. 
IxorixAi.   HEKXIA. 

Represents  all  of  the  anatomical  structures  laid  bare,  the  first  incision  having 
extended  down  to  the  fascia  of  the  external  oblique  abdominal  muscle,  the  next 
incision  having  split  the  fascia  of  the  external  oblique,  which  has  been  retracted, 
exposing  the  hernial  sac.  the  spermatic  curd.  Poupart's  ligament,  the  internal  oblique 
and  the  conjoined  tendon. 

Taken  from  Professor  A.  H.  Ferguson'-  Anginal  drawings,  with  his  kind  per- 
mission. 


GENERAL    SURGERY    OF    THE    ABDOMEN  391 

hernial  sac,  or  if  the  hernia  is  complicated  by  an  acute  inflammatory  con- 
dition, it  may  he  mistaken  for  an  inflammation  of  the  inguinal  lymphatic 
glands. 

The  latter  condition  is,  however,  usually  preceded  by  an  infection  of 
the  urethra  or  the  prepuce,  or  of  some  portion  of  the  lower  extremity  such 
as  may  come  from  an  infected  corn  or  from  some  slight  abrasion  of  the  skin. 

If  the  hernia  has  extended  down  into  the  scrotum  it  may  be  difficult  to 
differentiate  it  from  hematocele  or  a  hydrocele,  although  one  can  usually 
see  rays  of  light  shining  through  the  latter  by  placing  a  small  tube  against 
the  scrotum  and  holding  a  light  on  the  opposite  side.  Moreover,  by  grasp- 
ing the  tissues  opposite  the  external  abdominal  ring  between  the  finger  and 
thumb  one  can  always  feel  the  tissues  of  the  cord  above  a  hydrocele,  but  not 
above  a  hernia,  except  in  children  suffering  from  an  irreducible  hydrocele 
of  the  cord,  to  be  considered  later.  On  the  left  side  a  large  varicocele  is 
sometimes  mistaken  for  hernia  and  vice  versa.  This,  however,  should  not 
occur,  because  the  enlarged  veins  have  a  peculiar,  wormlike  feeling  in 
varicocele  which  may  be  easily  recognized. 

Occasionally  an  inguinal  hernia  and  a  femoral  hernia  occur  in  the  same 
patient,  and,  in  a  few  cases,  instead  of  extending  in  the  direction  of  the 
inguinal  canal  into  the  scrotum  an  inguinal  hernia  will  descend  to  the  upper 
portion  of  the  scrotum  and  then  be  deflected  outward  to  a  point  opposite 
the  femoral  ring,  and  thus  have  the  appearance  of  a  femoral  hernia. 

In  a  similar  manner  a  femoral  hernia,  instead  of  descending  after  pro- 
truding through  the  femoral  opening,  may  extend  upward  and  form  a 
swelling  in  the  region  of  the  inguinal  canal  and  thus  have  the  appearance 
of  an  inguinal  hernia.  So  long  as  the  hernia  is  reducible  in  either  case  the 
diagnosis  can  readily  be  made,  because  the  opening  through  which  the 
hernia  has  protruded  can  be  demonstrated  by  digital  examination ;  if  this 
is  above  Poupart's  ligament  it  is  an  inguinal,  if  below,  a  femoral  hernia. 

Tumors  are  very  rare  in  the  region  of  the  inguinal  canal,  but  we  have 
seen  a  lipoma  and  several  sarcomata  which  had  been  diagnosed  as  inguinal 
hernia. 
Etiology. 

There  can  be  no  doubt  but  that  there  is  an  hereditary  tendency  in 
many  families  to  the  formation  of  hernia.  If  both  parents  in  a  family 
suffer  from  this  defect  some  of  the  children  are  almost  certain  to  be  af- 
flicted in  the  same  manner.  The  well-known  fact  that  special  defects  in 
families  are  likely  to  be  inherited  is  shown  in  this  disease.  There  is  a  much 
larger  proportion  of  hernise  in  nationalities  in  which  intermarriage  be- 
tween first  cousins  is  freely  practised  than  in  others  in  which  this  is  for- 
bidden. 

The  natural  opening  in  the  inguinal  canal  in  the  male,  due  to  the  de- 
scent of  the  testicle,  makes  the  occurrence  of  inguinal  hernia  much  more 
common  than  in  the  female. 

Long  continued,  exhausting  diseases  cause  a  relaxation  of  the  tissues 
of  the  abdominal  wall,  which  predisposes  to  the  formation  of  hernia. 

In  a  considerable  proportion  of  cases  the  inguinal  canal  had  never 
been  completely  closed  after  the  descent  of  the  testicle,  and  it  required 
only  a  slight  dilatation  of  the  internal  abdominal  ring,  followed  by  a  sud- 
den increase  of  pressure,  to  force  down  some  of  the  intra-abdominal  con- 
tents, and  the  hernia  is  thus  established.  A  long,  thin  omentum  greatly 
favors  this  last  step. 


392  GENERAL    SUKGKKY     OF    THK    ABDOMKN 

Indications  for  Operation. 

In  our  typical  patient  the  hernia  can  be  readily  reduced  and  retained 
by  means  of  a  truss,  hence  the  conditions  are  very  similar  to  those  dis- 
cussed in  connection  with  femoral  hernia.  We  can  undoubtedly  relieve 
this  patient  of  the  discomforts  of  wearing  a  truss,  and  the  dangers  of  a 
possible  strangulation,  by  a  safe  operation,  which  will  disable  him  for  work 
not  longer  than  one  month.  There  can  consequently  be  little  doubt  concern- 
ing the  wisdom  of  his  choice  of  treatment. 

Preparation  for  Operation. 

The  intestinal  canal  should  be  thoroughly  emptied  by  the  administra- 
tion of  two  ounces  of  castor  oil  the  day  before  operation,  followed  by  a 
large  soap  and  water  enema  that  evening  and  another  early  on  the  morn- 
ing of  operation.  The  field  of  operation  should  be  shaved  the  evening  be- 
fore operation  and  the  following  morning  the  patient  takes  a  hot  soap  and 
water  tub  bath.  As  soon  as  the  patient  is  anesthetized  the  skin  area  is 
washed  thoroughly  with  soap  and  water  (being  careful  not  to  cause  irrita- 
tion), then  it  is  washed  with  1-2,000  bichloride  solution,  then  with  alcohol. 
The  surface  is  dried  and  painted  with  full  strength  compound  tincture  of 
iodine. 

Operative  Technique. 

An  incision  ten  to  fifteen  centimeters  in  length  is  made  in  the  direc- 
tion, and  over  the  center,  of  the  inguinal  canal,  beginning  at  a  point  two 
centimeters  above  the  scrotum.  This  is  carried  through  the  skin,  superficial 
fascia  and  fat,  exposing  the  fascia  of  the  external  oblique  abdominal  mus- 
cle with  the  hernial  sac  protruding  at  the  lower  end  of  the  inguinal  canal, 
<-;s  shown  in  plate. 

The  fascia  of  the  external  oblique  is  now  slit  up  in  the  direction  of  the 
inguinal  canal  to  a  point  five  centimeters  above  the  internal  abdominal 
ring.  The  edges  of  this  are  now  carefully  retracted,  and  the  soft  tissues, 
consisting  of  fat,  portions  of  the  cremasteric  muscle  and  connective  tissue, 
are  carefully  dissected  away,  leaving  the  anatomical  structures  plainly  ex- 
posed, as  shown  in  plate.  The  fat  can  be  removed  most  perfectly  and  rap- 
idlv  by  stripping  between  the  layers  of  a  piece  of  moist  gauze  held  between 
the  fingers  and  thumb.  This  exposes  the  ledge  of  Poupart's  ligament  and 
the  fascia  of  the  external  oblique  below,  the  internal  oblique  and  trans- 
versalis  fascia  and  the  fascia  of  the  external  oblique  above,  and  between 
these  the  hernial  sac  and  the  spermatic  cord;  and  to  the  outer  side,  the 
fibers  of  the  internal  oblique,  as  shown  in  plate. 

The  hernial  sac  is  now  carefully  dissected  out,  caution  being  taken  not 
to  injure  the  tissues  of  the  spermatic  cord,  which  in  this  case  we  find  con- 
tinuous with  the  upper  portion  of  the  sac,  showing  that  we  have  to  deal 
with  a  congenital  hernia,  the  tunica  vaginalis  having  remained  open  since 
birth,  the  internal  ring,  however,  being  so  nearly  closed  that  there  was  no 
protrusion  of  omcntum  until  many  years  later. 

In  order  to  facilitate  the  separation  of  the  upper  portion  of  the  sac  we 
will  open  the  latter.  It  contains  a  long,  thin  portion  of  omentum.  This 
is  drawn  down  gently  as  far  as  it  will  come  without  using  any  force.  It 
is  spread  out  and  the  vessels  are  ligated  by  passing  around  them  catgut 
ligatures  at  each  point  at  which  they  can  be  seen  by  holding  up  the  spread 
omentum  to  the  light.  Then  the  omentum  is  cut  away  beyond  these  liga- 


PLATE  XLVIT. 

INGUINAL  HERNIA. 

Represent?  the  fascia  of  the  external  oblique  retracted,  the  internal  oblique  and 
conjoined  tendon  sutured  to  the  ledge  in  Poupart's  ligament,  the  spermatic  cord 
remaining  undisturbed  in  its  normal  position. 

Taken  from  Professor  A.  H.  Ferguson's  original  drawings,  with  his  kind  per- 
mission. 


PLATE  XLVIIT. 

INGUINAL  HERNIA. 

This  figure  shows  the  sutures  attaching  the  internal  oblique  and  transversalis 
abdominal  muscles  to  Poupart's  ligament,  in  place  and  over  these  tissues  the  fascia 
of  the  external  oblique  sutured  in  a  separate  layer,  the  spermatic  cord  issuing  at 
the  lower  angle.  Suturing  the  skin  and  superficial  fascia  over  all  will  complete  the 
operation. 

Taken  from   Professor  A.   H.   Ferguson's  original   drawings,  with  his  kind  per- 


PLATE  XL1X. 

BASSIXI'S  OPERATION  FOR  RADICAL  CURE  OF  INGUINAL  HERNIA. 
A  fascia  of  external  oblique  abdominal  muscle;  B  Poupart's  ligament:  C  con- 
joined tendon;  D  internal  oblique  abdominal   muscle;   E  spermatic  cord.     Chro- 
micized  catgut   sutures  above  cord:   f  tbe   same  belcv:  cord. 


GENERAL    SURGERY    OF    THE    ABDOMEN  399 

tures,  preserving  enough  tissue  to  prevent  slipping.  The  sac  is  now  dis- 
sected up  to  a  point  quite  within  the  abdominal  cavity ;  it  is  then  transfixed 
with  a  needle  carrying  a  double  catgut  ligature  and  tied  so  as  to  prevent 
slipping.  The  sac  is  cut  away,  care  being  taken  to  leave  enough  tissue  to 
prevent  the  slipping  of  the  ligature.  The  stump  is  now  retracted  within 
the  abdominal  cavity  by  the  elasticity  of  the  peritoneum. 

The  steps  which  have  just  been  described  are  exceedingly  important, 
especially  the  careful  removal  of  the  soft  tissues,  the  hernial  sac  and  the 
omentum,  because  neglect  of  any  one  of  these  points  would  tend  to  cause 
a  recurrence. 

The  internal  oblique  muscle  and  transversalis  fascia  are  now  carefully 
sutured  with  interrupted  sutures  of  chromicized  catgut  to  the  ledge  upon 
the  under  surface  of  Poupart's  ligament,  the  edge  of  the  fascia  of  the  ex- 
ternal oblique  being  carefully  retracted,  as  shown  in  plate. 

In  applying  these  sutures,  it  is  well  to  bear  in  mind  the  possibility  of 
injuring  the  deep  epigastric  vessels  by  carelessly  grasping  the  tissues  above 
with  the  stitch,  or  the  iliac  vessels  below  in  the  same  manner.  The  simplest 
way  to  avoid  injuring  the  latter  is  to  insert  the  needle  through  Poupart's 
ligament  from  within  outward. 

The  fascia  of  the  external  oblique  muscle  is  then  sutured  as  shown  in 
plate.  The  skin  is  then  sutured  over  all. 

This  method,  known  as  Ferguson's  operation,  has  the  advantage  of 
closing  the  inguinal  canal  perfectly,  firmly  and  permanently,  and  at  the 
same  time  leaving  the  tissues  of  the  spermatic  cord  undisturbed. 

Since  the  publication  of  this  method  by  Dr.  Ferguson  we  have  used 
it  because  it  combined  all  of  the  good  qualities  of  Bassini's  operation,  which 
we  had  practised  with  most  excellent  results  for  a  number  of  years  pre- 
viously, and  has  the  advantage  of  being  simpler  in  that  it  does  not  disturb 
the  tissues  of  the  spermatic  cord. 

In  order  to  illustrate  the  latter  method,  however,  especially  as  it  is 
the  one  still  in  use  by  most  of  the  best  surgeons,  we  will  perform  Bassini's 
operation  upon  the  other  side.  For  the  sake  of  simplicity  we  can  make  use 
of  the  illustrations  just  shown  of  a  herniotomy  upon  the  left  side,  because 
all  the  steps,  with  one  exception,  are  identical. 

The  incision,  the  exposure  of  the  anatomical  layers,  the  removal  of  the 
soft  tissues  and  the  hernial  sac  are  the  same.  In  the  last  step,  however, 
we  find  this  difference :  The  sac  is  not  continuous  with  the  tissues  of  the 
spermatic  cord,  but  is  simply  adherent  by  means  of  delicate  fibers  of  con- 
nective tissue,  showing  that  on  this  side  we  have  an  acquired  and  not  a 
congenital  hernia. 

We  also  find  that  the  sac  contains  no  omentum.  It  is  likely  that  this 
descended  into  one  side  occasionally  and  then  into  the  other,  or  the  other 
side  may  have  contained  omentum  and  this  side  intestines  regularly.  Hav- 
ing disposed  of  the  hernial  sac  as  before,  we  make  the  step  in  the  operation 
in  which  the  two  methods  named  differ.  The  tissues  of  the  spermatic 
cord  are  carefully  loosened  from  all  of  the  surrounding  tissues.  Then 
we  elevate  it  from  the  floor  of  the  inguinal  canal  by  means  of  a  blunt  hook 
and  insert  the  stitches  of  chromicized  catgut,  as  shown  in  plate.  These 
stitches  are  applied  precisely  as  before,  grasping  the  same  tissues.  Two 
of  them  being  applied  above  the  cord  and  the  others  underneath  the  ele- 
vated cord,  so  that  the  latter  passes  out  between  the  second  and  third 
stitch,  counting  from  the  outer  side.  Six  stitches  will  usuallv  suffice.  Thev 


4OO  GENERAL    SUKGEKY    OF    THE    ABDOMEN 

may  be  applied  with  greater  regularity  if  they  are  not  tied  until  all  are  in 
place.  The  same  care  must  be  taken  to  prevent  the  injury  of  the  deep  epi- 
gastric and  iliac  vessels  as  before. 

The  two  stitches  above  the  cord  are  of  the  greatest  importance,  be- 
cause it  is  at  this  point  that  recurrence  is  likely  to  take  place.  After  these 
stitches  have  been  tied  the  fascia  of  the  external  oblique  muscle  and  the 
skin  are  sutured  as  before. 

Variations  in  Technique. 

Occasionally  the  tissues  to  the  inner  side  of  the  inguinal  canal  are  so 
attenuated  that  it  seems  difficult  to  secure  a  permanent  closure  of  the 
hernial  opening.  In  this  event  it  may  become  necessary  to  utilize  the 
rectus  abdominis  muscle — Bloodgood's  method.  The  fascia  covering  the 
outer  edge  of  the  rectus  abdominis  muscle  is  split  longitudinally  and  the 
muscle  is  then  sutured  to  Poupart's  ligament,  together  with  the  conjoined 
tendon  of  the  internal  oblique  and  transversalis. 

Prognosis. 

Both  of  these  operations,  if  performed  with  great  care,  will  result  in 
a  permanent  cure  of  inguinal  hernia  in  almost  every  case,  provided  that 
the  patient  prevents  for  the  future  the  recurrence  of  abnormal  intra-ab- 
dominal  pressure. 

In  the  female  patient  the  operation  is  done  precisely  in  the  same  man- 
ner, with  the  exception  that  the  round  ligament,  which  corresponds  to  the 
tissues  of  the  spermatic  cord,  is  practically  disregarded. 

FEMORAL  HERNIA. 
Clinical   Case. 

An  unmarried  woman,  twenty-eight  years  of  age,  a  servant  by  occupa- 
tion, gives  the  following  history : 

Her  parents,  brothers  and  sisters  are  well.  She  was  well  and  strong 
as  a  child ;  menstruation  since  the  age  of  sixteen,  regular  and  normal.  She 
has  worked  hard  as  a  servant  since  the  age  of  twenty.  At  twenty-two  she 
first  noticed  a  slight  protrusion  in  the  region  of  the  left  femoral  canal.  This 
has  increased  gradually.  It  is  now  the  size  of  a  hen's  egg.  She  can  reduce 
it  readily,  but  suffers  from  a  dragging  pain  when  working  hard ;  in  fact, 
even  when  she  is  compelled  to  stand  or  walk  she  is  very  uncomfortable. 

She  is  well  nourished,  the  various  organs  are  normal,  both  as  regards 
their  anatomical  position  and  physiological  functions.  Upon  standing 
a  swelling  develops  in  the  left  femoral  region  to  the  size  of  a  hen's  egg. 
The  swelling  disappears  instantly  upon  resuming  the  recumbent  position, 
and  an  opening  that  will  admit  the  tip  of  a  finger  can  be  felt  under  Poupart's 
ligament.  There  is  an  impulse  upon  coughing  or  straining. 

The  history  and  physical  examination  leave  no  doubt  as  to  the  diag- 
nosis. It  is  an  uncomplicated  case  of  femoral  hernia. 

Differential  Diagnosis. 

If  a  portion  of  the  omentum  becomes  attached  to  the  lining  of  the 
hernial  sac,  on  account  of  inflammatory  adhesions,  it  may  occasionally 
be  mistaken  for  lymphadenitis  of  the  glands  normally  found  in  this  region. 

Lipoma  has  been  mistaken  for  femoral  hernia:  the  same  is  true  of 
sarcoma.  All  of  these  condition?  can,  however,  be  eliminated  in  this  case. 


PLATE  L. 
Typical  appearance  of  femoral  hernia. 


PLATE  LI. 

Showing  anatomy  of  the   femoral   region. 


GENERAL    SURGERY    OF    THE    ABDOMEN  405 

because  there  is  a  definite  femoral  canal  when  the  swelling  is  reduced,  and 
there  is  a  distinct  impulse  upon  coughing  or  straining.  Moreover,  the  con- 
dition is  too  chronic  for  either  sarcoma  or  lymphadenitis. 

The  history  is  interesting  from  one  point  alone,  which  probably  ex- 
plains the  origin  of  this  hernia. 
Etiology. 

So  long  as  this  patient  remained  at  home  and  simply  performed  her 
share  of  the  duties  in  the  household  of  her  parents,  who  were  working  peo- 
ple with  a  small  income,  she  remained  perfectly  well.  She  went  into  service 
as  a  domestic  and  was  compelled  to  labor  beyond  her  strength,  and  conse- 
quently soon  became  relaxed.  When  she  lifted  heavy  wash  boilers,  and 
overexerted  herself  in  other  ways,  immediately  the  point  of  weakness  in 
her  femoral  region  became  apparent.  The  peritoneal  protrusion  formed 
a  hernial  sac  and  as  the  omentum  or  intestine  was  forced  into  this  sac  the 
latter  slowly  increased,  until  it  acquired  its  present  size. 

Femoral  hernia  is  almost  always  acquired  at  a  time  when  the  patient 
is  exposed  to  an  abnormal  strain,  most  commonly  during  the  child-bearing 
period  or,  as  in  this  case,  during  a  time  of  hard  domestic  service. 

The  treatment  may  be  palliative,  by  means  of  a  truss  which  could  un- 
doubtedly be  adjusted,  or  curative,  by  means  of  an  operation. 

There  are  no  strong  indications  in  this  case.  Her  suffering  is  not  se- 
vere, she  is  not  disabled  for  work,  nor  is  she  in  great  danger  of  becoming 
worse.  The  only  danger  is  from  strangulation,  and  this  is  not  great,  be- 
cause the  opening  through  which  the  hernial  contents  enter  the  sac  seems 
to  be  sufficiently  large  to  permit  an  easy  reduction.  Should  there  develop 
a  more  marked  disproportion  between  this  part  and  the  remaining  portion 
of  the  sac,  strangulation  would  be  more  likely  to  occur.  Whatever  is  done 
for  this- patient  is  consequently  not  a  matter  of  necessity,  but  one  of  choice. 

Although  a  truss  would  probably  retain  this  hernia,  it  is  not  to  be 
chosen  lightly,  for  it  will  be  a  hardship  for  this  patient  to  be  subjected  to 
the  discomfort  of  wearing  this  very  uncomfortable  instrument  for  the  re- 
mainder of  her  life.  Moreover,  such  a  course  would  be  connected  with 
considerable  expense.  Trusses  have  to  be  changed  and  repaired  and  are 
never  comfortable  to  wear. 

On  the  other  hand,  in  choosing  an  operation  for  this  condition  we 
must  be  reasonably  certain  of  three  things,  viz.,  i.  It  must  be  almost  abso- 
lutely safe.  (This  patient  is  now  in  good  health  and  is  likely  to  remain 
so  for  a  long  time  if  no  operation  be  performed,  therefore  we  take  a  great 
responsibility  in  advising  an  operation  if  it  is  not  safe.)  2.  The  result  must 
be  permanent.  3.  The  patient  must  not  be  disabled  for  work  for  too  long 
a  time. 

It  is  believed  that  all  of  these  conditions  may  obtain  under  right  man- 
agement. 

The  ordinary  preparations  of  the  patient  in  general  and  of  the  field 
of  operation  are  made. 

Operative  Steps. 

An  incision  is  made  over  the  most  prominent  portion  of  the  swelling, 
either  parallel  with  the  axis  of  the  body  or  with  Poupart's  ligament.  The 
center  of  this  incision  should  be  over  the  middle  of  the  femoral  canal. 

After  the  skin  and  superficial  fascia  have  been  severed  it  is  best  to 


406  GENERAL    SURGERY    OF    THE    ABDOMEN 

lift  the  underlying  tissues  by  means  of  two  pairs  of  dissecting  forceps,  in 
order  to  protect  each  successive  layer  of  tissue.  This  will  greatly  facilitate 
the  operation  and  at  the  same  time  increase  the  safety  to  the  patient. 

It  is  usually  not  difficult  to  recognize  the  sac  on  account  of  its  smooth, 
hard  structure,  but  if  the  tissues  have  been  severely  irritated  by  pressure 
from  a  truss  it  then  is  often  more  difficult.  It  can,  however,  always  be 
recognized  after  it  has  been  opened  on  account  of  the  smooth  peritoneal 
lining  and  usually  there  is  an  escape  of  hernial  fluid  as  soon  as  the  sac  is 
incised. 

If  the  sac  is  recognized  before  opening  it  should  be  carefully  sep- 
arated from  the  surrounding  tissues  to  a  point  quite  within  the  femoral 
ring.  It  should  then  be  opened  to  determine  its  contents.  If  it  contains 
intestines,  these  should  be  replaced  into  the  peritoneal  cavity;  if  omentum, 
it  is  well  to  grasp  this  with  forceps  and  draw  it  down  until  a  slight  amount 
of  resistance  indicates  the  fact  that  all  of  that  portion  which  has  occasion- 
ally descended  in  the  hernial  sac  has  been  drawn  down.  If  the  amount  is 
considerable  it  should  be  ligated  in  a  sufficient  number  of  portions  to  pre- 
vent its  being  tied  in  a  mass  large  enough  to  cause  irritation  by  its  pres- 
ence in  the  abdominal  cavity. 

The  ligatures  should  consist  of  catgut  or  fine  silk,  which  should  be 
applied  just  tightly  enough  to  control  the  hemorrhage,  but  not  sufficient 
to  crush  the  tissues.  It  is  well  to  tie  three  times  if  catgut  is  used,  because 
the  peritoneal  fluid  has  a  tendency  to  soften  this  material  and  cause  the 
knot  to  loosen.  The  portion  beyond  the  ligatures  is  cut  away,  care  being 
taken  to  leave  enough  tisue  to  prevent  slipping.  For  the  same  reason  great 
care  must  be  used  in  replacing  the  stump. 

It  is  important  to  dispose  of  the  long,  thin  portions  of  omentum  in 
this  manner,  because  if  left  undisturbed  they  are  likely  to  become  insin- 
uated in  any  slight  depression  which  may  be  left  in  the  abdominal  wall  at 
the  point  of  the  operation  and  hence  predispose  to  recurrence. 

The  hernial  sac  is  then  grasped  by  means  of  hemostatic  forceps  and 
drawn  out  of  the  wound  as  far  as  possible  without  tearing  it  loose,  as 
shown  in  the  accompanying  plate.  It  is  then  ligated  as  highly  as  possible 
with  catgut  or  fine  silk.  It  is  best  to  transfix  the  neck  of  the  sac  with  the 
ligature  mounted  upon  a  needle,  and  to  tie  first  to  one  side  and  then  to 
the  other,  so  as  to  prevent  slipping  of  the  ligature  when  the  pedicle  is 
dropped.  A  sufficient  portion  of  the  sac  should  be  left  outside  of  the  lig- 
ature to  prevent  slipping,  as  shown  in  the  accompanying  figure. 

When  the  sac  has  been  cut  away  the  stump  will  retract  within  the 
peritoneal  cavity  and  the  ring  be  left  without  a  lining. 

If  the  cavity  formed  by  the  removal  of  the  sac  contains  masses  of  fat, 
these  should  be  removed.  This  may  be  accomplished  in  a  moment  by  grasp- 
ing these  masses  with  a  piece  of  moist  gauze.  The  fat  seems  to  cling  to 
the  rough  gauze,  while  the  other  structures  slip  through  your  grasp.  A 
perfectly  clean  dissection  can  be  made  in  this  way  in  a  few  minutes  without 
harm  to  blood-vessels  and  nerves,  which  would  require  a  considerable  time 
if  made  with  dissecting  forceps  and  scalpel. 

This  virtually  completes  the  operation  with  the  exception  of  a  row  of 
superficial  sutures  closing  the  skin. 

If  one  observes  the  anatomical  conditions  present,  as  shown  in  the 
accompanying  diagram,  it  is  plain  that  any  attempt  at  closing  the  femoral 
canal  after  the  hernial  sac  has  been  removed,  must  to  some  extent  favor 


PLATE  LII. 
FEMORAL  HERNIA. 

Represents  a  femoral  hernia,  the  entire  sac  having  been  dissected  free  to  a  point 
within  the  femoral  ring,  then  transfixed  and  ligated,  the  sac  being  drawn  out  of 
the  wound  with  forceps,  the  scissors  being  in  position  to  cut  away  the  sac  beyond 
the  ligature. 


GENERAL    SURGERY    OF    THE    ABDOMEN 


409 


the  production  of  a  recurrence,  because  this  canal  is  almost  a  perfect  ring 
in  most  cases. 

It  is  a  well-known  fact  that  it  is  practically  impossible  to  keep  any 
ring-  in  the  human  body  open  unless  it  is  lined  with  mucous  membrane,  or 
includes  a  serous  membrane  containing  fluid ;  consequently  the  most  cer- 
tain method  of  closing  this  ring  consists  in  removing  the  serous  membrane 
by  removing  the  hernial  sac  to  a  point  within  the  abdominal  cavity  and 
permitting  the  ring  to  close  spontaneously.  After  applying  this  plan  to  a 
large  number  of  femoral  hernise  we  are  convinced  that  it  is  quite  as  im- 
possible to  keep  this  ring  open,  unless  it  is  distorted  by  one  of  the  many 
methods  which  have  been  devised  for  its  closure,  as  it  is  to  keep  any  other 
ring  or  canal,  not  lined  with  serous  or  mucous  membrane,  open.  In  other 
words,  all  of  the  methods  which  have  been  devised  for  closing  this  ring 


are  more  or  less  harmful  and  tend  to  cause  a  certain  number  of  recurrences. 
Of  course,  if  the  ring  has  been  injured  during  the  reduction  of  a  strangu- 
lated hernia,  which  could  not  be  accomplished  without  cutting  the  ring, 
then  this  injury  must  be  repaired  in  order  to  restore  the  original  favorable 
conditions. 

In  case  of  femoral  hernia  due  to  a  severe  traumatism,  especially  a  vio- 
lent  blow  upon  this  portion  of  the  body,  Poupart's  ligament  is  occasionally 
separated  for  some  distance  from  its  attachment  and  then  the  femoral  open- 
ing may  not  be  a  perfect  ring,  but  a  broad  gap.  In  such  event  it  is  occa- 
sionally wise  to  freshen  the  edges  of  this  irregular  opening  and  to  con- 
struct, as  nearly  as  possible,  a  perfect  ring.  There  is,  however,  only  a 
very  small  proportion  of  cases  in  which  this  is  necessary.  Indeed,  it  seems 
as  though  the  tissues  forming  the  femoral  rin.^  were  increased  in  amount 
to  quite  a  marked  extent  by  the  irritation  due  to  the  presence  of  the  hernia, 


410  GENERAL  SURGERY  OF  THE  ABDOMEN 

and  when  once  deprived  of  its  serous  lining  by  the  removal  of  the  hernial 
sac  this  ring  contracts  and  closes  with  astonishing  rapidity. 

In  most  all  these  patients  it  is  best,  if  possible,  to  institute  systematic 
treatment  for  a  month  or  two  before  performing  the  operation,  with  a 
view  to  reducing  the  obesity. 

After-Treatment. 

It  is  important  to  prevent  for  a  short  time  the  protrusion  of  the  peri- 
toneum into  the  femoral  ring  in  order  to  secure  for  this  part  the  best  pos- 
sible conditions  for  contracting  and  closing  permanently.  This  may  be 
favored  in  two  ways :  first,  by  reducing  the  intra-abdominal  pressure,  and, 
second,  by  keeping  the  contents  of  the  abdominal  cavity  from  approaching 
the  seat  of  the  operation. 

Abnormal  intra-abdominal  pressure  may  be  continuous  as  a  result  of 
the  accumulation  of  gas  in  the  alimentary  canal,  or  as  a  result  of  obesity ; 
or  it  may  be  intermittent,  as  in  vomiting  or  coughing,  or  if  the  patient 
suffers  from  constipation  and  has  to  employ  an  abnormal  amount  of  intra- 
abdominal  pressure  during  the  evacuation  of  the  bowels.  Very  rarely 
there  is  a  form  of  continuous  intra-abdominal  pressure  affecting  herniae 
in  case  of  ascites. 

The  intestines  and  the  omentum  may  be  kept  away  from  the  region 
of  operation  by  elevating  the  foot  of  the  bed  six  or  eight  inches  during 
the  first  week  following  the  operation,  at  the  end  of  which  time  the  fem- 
oral ring  will  have  contracted  sufficiently  to  prevent  any  protrusion.  This 
posture,  however,  is  not  safe  for  patients  who  are  advanced  in  age,  be- 
cause in  them  it  is  likely  to  cause  a  hypostatic  congestion  of  the  lungs, 
which  may  result  in  pneumonia. 

The  abdominal  pressure  due  to  constipation  can,  of  course,  be  readily 
relieved,  not  only  for  the  time  immediately  following  the  operation,  but 
the  patient  should  understand  the  importance  of  remaining  perfectly  free 
from  this  source  of  trouble.  This  will  also  in  a  great  measure  remove  an- 
other important  cause  of  abnormal  intra-abdominal  pressure,  that  due  to 
gaseous  distension  of  the  stomach  and  intestines.  This  may  be  overcome 
readily  for  the  time  immediately  following  the  operation  by  having  the 
alimentary  canal  thoroughly  evacuated  on  the  day  before  by  the  free  use 
of  a  cathartic,  preferably  by  the  administration  of  two  ounces  of  castor 
oil  in  the  foam  of  beer  or  malt,  the  use  of  enemata  and  the  prohibition  of 
any  form  of  food  which  is  likely  to  produce  gas. 

During  the  first  and  second  days  after  operation  the  patient  is  given 
hot  water  flavored  with  a  little  beef  extract,  if  desired,  then  some  pre- 
pared, predigested  food  is  given  every  three  hours  for  a  few  days,  then 
milk  and  lime  water,  then  soup,  and  after  ten  days  or  two  weeks  a  light 
diet  is  allowed. 

Aside  from  the  immediate  benefit  to  the  patient  there  is  the  further 
advantage  in  this  plan  of  feeding  that  the  digestive  organs  are  given  an 
opportunity  to  rest  and  recuperate  from  the  results  of  their  abuse,  which 
has  usually  been  long-continued  and  vigorous. 

UMBILICAL  HERNIA. 
Example. 

The  patient  is  forty-nine  years  of  age,  a  housewife,  whose  history 
was  of  no  medical  importance  until  nineteen  years  ago.  At  that  time, 


PLATE  LIII. 

UMBILICAL  HERNIA. 

Represents  the  hernial  ring  in  an  umbilical  hernia  laid  bare,  with  the  tissues  dis- 
sected back  down  to  the  aponeurosis.  Two  fingers  of  one  hand  are  inserted  into  the 
abdominal  cavity  in  order  to  protect  the  intra-abdominal  organs  against  injury  from 
the  needle,  which  is  inserted  one  and  one-half  to  two  inches  from  the  edge  of  the 
ring.  A  blunt  hook  is  inserted  on  either  side  to  stretch  the  ring  transversely. 


GENERAL    SURGERY    OF    THE    ABDOMEN  413 

during  an  attack  of  whooping  cough,  she  noticed  a  slight  bulging  in  the 
region  of  the  umbilicus.  Six  months  later  during  the  birth  of  her  fourth 
and  last  child  this  condition  became  considerably  worse.  It  continued  to 
develop  slowly  until  ten  years  ago,  when  it  was  suddenly  increased  on  ac- 
count of  a  fall.  Patient  has  suffered  from  mild  melancholia  for  three 
years. 

Present  Condition. 

Obese  patient ;  pulse  and  temperature,  heart,  lungs  and  kidneys  nor- 
mal ;  bowels  constipated,  tongue  coated.  Abdominal  walls  very  thick.  A 
protrusion  is  noticed  at  the  umbilicus,  the  size  of  a  small  fist,  covered  with 
very  thin  skin.  The  mass  cannot  be  reduced  into  the  peritoneal  cavity 
and  is  very  tender  upon  pressure.  There  is  also  tenderness  upon  pressure 
in  the  right  inguinal  region. 

The  condition  present  in  this  patient  can  give  rise  to  but  one  diagnosis 
— umbilical  hernia. 

Etiology. 

This  hernia  was  brought  about  in  the  usual  manner  and  under  the 
usual  conditions.  The  abdominal  wall  had  suffered  from  the  effects  of 
three  pregnancies ;  it  had  been  weakened  by  an  abnormal  amount  of  fat ; 
then  it  was  taxed  beyond  its  strength  by  the  increased  intra-abdominal 
pressure  caused  by  the  whooping  cough.  To  this  was  added  another  preg- 
nancy and  later  a  fall.  Each  of  these  factors  favored  the  fvirther  weak- 
ening of  the  abdominal  wall  and  the  increase  of  the  hernial  protrusion. 

Influence  of  Age. 

In  childhood  a  hernia  in  this  position  will  heal  spontaneously  in  al- 
most every  case,  provided  the  increased  intra-abdominal  pressure  is  elim- 
inated, because  the  opening  is  a  perfect  ring  composed  of  tissue  which  has 
the  tendency  to  contract.  It  is  quite  different  in  patients  over  thirty  years 
of  age.  The  increasing  obesity  primarily  overcomes  the  tendency  of  the 
tissues  forming  the  ring  to  contract ;  moreover,  the  abdomen  broadens, 
while  the  distance  between  the  sternum  and  the  pubis  decreases ;  hence  the 
ring  is  distorted,  which  again  interferes  with  its  closure. 

Still  again,  the  omentum  which  has  been  forced  into  the  hernial  sac 
forms  inflammatory  adhesions  and  this  permanently  prevents  the  closing 
of  the  ring. 

Remedial  Measures. 

Were  the  hernia  reducible  there  might  be  a  choice  between  palliative 
measures  consisting  in  the  fitting  of  a  truss,  and  radical  measures  consist- 
ing in  an  operation  for  permanent  cure.  We  have  consequently  the  choice 
between  giving  this  patient  an  abdominal  bandage  with  a  pouch-like  ar- 
rangement in  which  to  carry  her  hernia,  and  performing  an  operation. 

Indications  for  Operation. 

The  patient  is  virtually  disabled  for  performing  her  household  duties, 
because  there  is  a  constant  dragging  feeling  in  the  region  of  the  umbilicus 
due  to  the  adhesion  of  the  omentum.  For  the  same  reason  she  is  unable 
to  walk,  and  as  a  result  of  this  she  is  compelled  to  lead  a  sedentary  life, 
which  causes  her  obesity  to  increase.  There  is  a  kind  of  vicious  circle  es- 
tablished. The  increase  in  the  hernia  prevents  her  from  exercising  suffi- 
ciently to  reduce  her  obesity  and  this  in  turn  favors  the  increase  in  the 


414  GENERAL    SURGERY    OF    THE    ABDOMEN 

hernia.     Unless  she  is  relieved  of  her  hernia  she  will  become  more  and 
more  helpless. 

Preparatory  Treatment 

The  patient  has  come  to  the  city  from  a  distance  and  is  compelled,  on 
account  of  her  financial  circumstances,  to  return  home  as  soon  as  pos- 
sible. It  is  also  impossible  for  her  to  return  home  and  come  to  the  hos- 
pital later  for  the  operation.  Were  it  not  for  these  circumstances,  it  would 
be  much  better  to  first  place  her  under  treatment  for  the  reduction  of  her 
obesity.  The  same  plan  would  be  followed  which  has  already  been  de- 
scribed in  connection  with  femoral  hernia.  This  being  out  of  question, 
we  have  reduced  the  intra-abdominal  pressure  as  much  as  possible  by  the 
use  of  saline  cathartics,  and  placing  the  patient  upon  a  diet  of  beef-tea  for 
a  few  days,  also  giving  hot  baths  followed  by  cold  showers  and  massage. 

The  Mayo  Technique. 

Of  all  hernise  this  form  has  been  most  difficult  to  treat  surgically  and 
has  given  a  larger  percentage  of  recurrences  than  any  other.  This  has, 
however,  changed  since  the  introduction  of  Mayo's  operation  some  nine 
years  ago,  which  has  made  the  results  in  this  form  of  herniotomy  quite  as 
satisfactory  as  in  the  inguinal  variety. 

The  operation  comprises  the  following  steps : 

(1)  "Transverse   elliptical   incisions   are   made   surrounding  the   um- 
bilicus and  hernia;  deepened  to  the  base  of  the  hernial  protrusion. 

(2)  The  surfaces  of  the  aponeurotic  structures  are  carefully  cleared 
an  inch  and  a  half  in  all  directions  from  the  neck  of  the  sac. 

(3)  The  fibrous  and  peritoneal  coverings  of  the  hernia  are  divided 
in  a  circular  manner  at  the  neck,  exposing  its  contents.     If  intestinal  viscera 
are  present  the  adhesions  are  separated  and  restitution  made.     The  con- 
tained omentum  is  ligated  and  removed  with  the  entire  sac  of  the  hernia. 

(4)  With  forceps  the  margins  of  the  ring  are  grasped  and  approxi- 
mated.    Whichever  way  the  overlapping  is  more  easy  of  accomplishment, 
suggests   the   direction   of   the   closure.     The   illustrations   show   the  over- 
lapping as  done  from  above  downward. 

(5)  For   this   approximation   an   incision   is   made   through   the   apo- 
neurotic and  peritoneal  structures  of  the  ring  extending  one  inch  or  more 
transversely  to  each  side,  and  the  peritoneum  is  separated  from  the  under 
surface  of  the  upper  of  the  two  flaps  thus  formed. 

(6)  Beginning  from  one  to  one  and  one-half  inches  above  the  mar- 
gin of  the  upper  flap,  three  to  four  chromicized  catgut  mattress  sutures 
are  introduced,  the  loop   firmly  grasping  the   upper  margin   of   the  lower 
flap ;  sufficient  traction  is  made  on  these  sutures  to  enable  peritoneal  ap- 
proximation  with   running   sutures   of   catgut.      The   mattress   sutures   are 
then  drawn  into  position,  sliding  the  entire  lower  flap  into  the  pocket  pre- 
viously formed  between  the  aponeurosis  and  the  peritoneum  above. 

(7)  The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures  to 
the  surface  of  the  aponeurosis  below,  and  the  superficial  incision  closed  in 
the  usual  manner.     The  lateral  approximation  is  carried  out  by  sliding  one 
side  under  the  other  in  the  same  manner.     In  the  larger  herniae  the  in- 
cision through  the  fibrous  covering  of  the  sac  may  be  made  somewhat  above 
the  base,  thereby  increasing  the  amount  of  tissue  to  be  used  in  the  over- 
lapping process." 


PLATE  LIV. 
UMBILICAL  HERNIA. 

Represents  three  chromicized  cat-gut  stitches  in  position.  The  cat-gut  is  repre- 
sented double.  This  is  not  important,  but  has  the  advantage  of  extra  security  in 
case  there  should  be  a  defect  in  one  strand,  besides  making  it  possible  to  use  a 
smaller  size  of  cat-gut. 


PLATE  LV. 
UMBILICAL  HERNIA. 

Represents  the  deep  stitches  tied,  carrying  the  lower  edge  of  the  wound  underneath 
the  upper  one,  with  the  stitches  inserted,  which  will  serve  to  unite  the  upper  edge 
of  the  ring  to  the  aponeurosis  of  the  abdominal  wall  below. 


GENERAL    SURGERY    OF    THE    ABDOMEN  419 

We  have  employed  chromicized  catgut  sutures  in  place  of  the  silver 
wire  sutures  in  all  cases  operated  by  Mayo's  method.  Having  been  called 
upon  frequently  to  remove  silver  wire  sutures  which  other  surgeons  had 
employed  in  various  operations,  we  have  abandoned  their  use  entirely  and 
found  that  chromicized  catgut  has  all  of  the  good  qualities  and  none  of 
the  bad  ones  of  silver  wire. 

Plate  LIII  shows  the  manner  in  which  the  stitches  are  introduced,  the 
fingers  protecting  the  intra-abdominal  structures  against  injury  from  the 
needle. 

Plate  LIV  shows  the  deep  stitches  in  place,  which  when  tied  will  slide 
one  edge  of  the  ring  underneath  the  other.  The  line  of  sutures  should  ex- 
tend transversely  across  the  body  instead  of  obliquely,  as  pictured  by  the 
artist.  In  all  of  our  cases  we  have  found  it  possible  to  close  the  opening 
without  tension  by  placing  the  line  of  sutures  in  this  direction. 

In  small  herniae  three  deep,  and  about  five  superficial,  sutures  will 
suffice,  but  the  number  may  be  increased  according  to  the  size  of  the 
opening. 

Plate  LV  shows  the  manner  in  which  the  overlapping  edge  of  the 
hernial  opening  is  sutured  to  the  aponeurosis. 

By  this  method  we  obtain  a  double  layer  of  the  strong  aponeurosis 
composed  of  the  fascia  of  the  external  and  internal  oblique  abdominal 
muscles,  together  with  the  transversalis  fascia. 

In  all  of  these  patients  we  have  observed  the  fact  that  they  have  a 
sense  of  security  and  strength  after  this  operation  which  none  formerly 
had  after  operations  for  the  relief  of  large  umbilical  hernia  by  other 
methods. 

Important  Points. 

Having  dissected  out  the  entire  hernial  sac,  together  with  its  over- 
lying thin  skin  down  to  the  edge  of  the  aponeurosis  forming  the  hernial 
ring,  we  must  plan  to  open  the  sac  and  dispose  of  its  contents. 

There  are  two  areas  in  which  the  omentum  is  usually  adherent  to  the 
sac,  one  opposite  the  most  superficial  portion,  the  other  along  the  edge  of 
the  hernial  ring. 

If  we  attempt  to  open  the  sac  opposite  either  of  these  points  we  will 
find  an  exceedingly  tedious  and  unsatisfactory  task.  It  is  quite  different 
if  we  open  the  sac  on  one  side  half-way  between  these  two  points,  where 
the  surfaces  are  usually  free  from  adhesions.  It  is  then  best  to  begin  at 
one  point  and  systematically  loosen  the  adhesions  between  the  omentum 
and  the  hernial  ring  until  the  former  is  entirely  free.  If  this  is  done  the 
entire  task  can  be  accomplished  in  a  few  minutes,  but  if  one  loosens  small 
areas  here  and  there  in  an  unsystematic  manner,  a  great  amount  of  time 
may  be  unnecessarily  consumed  to  the  detriment  of  the  patient. 

Should  the  sac  contain  intestines  still  greater  care  must  be  employed 
for  fear  of  causing  a  perforation.  Should  there  be  an  abrasion  on  the 
surface  of  the  intestine  this  should  be  covered  at  once  with  a  few  Lembert 
sutures. 

Having  loosened  all  of  the  adhesions  between  the  omentum  and  the 
hernial  ring,  it  becomes  necessary  to  dispose  of  the  mass  of  omentum.  The 
latter  is  usually  so  matted  together  that  it  would  undoubtedly  give  rise  to 
great  discomfort  from  pressure  were  it  to  be  returned  to  the  abdominal 
cavity;  it  is  consequently  best  to  ligate  it  in  a  number  of  portions,  to  cut 


GENERAL    SURGERY    OF    THE    ABDOMEN 

away  the  part  that  has  been  matted  together,  and  return  the  remaining  por- 
tion into  the  abdominal  cavity.  At  this  point  it  is  important  to  observe 
care  not  to  place  the  ligatures  too  near  the  transverse  colon  for  fear  of 
causing  necrosis. 

Prognosis. 

If  this  plan  of  treatment  is  followed  the  prognosis  in  these  cases  is 
astonishingly  good,  both  as  regards  immediate  and  permanent  results. 
After  Treatment. 

It  is  well  to  avoid  all  abnormal  It  tra-abdominal  pressure  (i)  by  re- 
ducing the  obesity  by  means  of  diet  a./id  vigorous  exercise,  preferably  walk- 
ing; (2)  by  avoiding  constipation;  (3)  by  regulating  the  diet  so  as  to 
avoid  gaseous  distension;  (4)  in  the  male  by  avoiding  obstruction  of  the 
urethra,  or  correcting  this  should  it  exist. 

Variation  of  Incision. 

Occasionally  one  will  find  a  small  umbilical  hernia  in  a  patient  to  be 
operated  for  some  other  intra-abdominal  condition,  like  tumors  of  the  pelvic 
organs,  appendicitis  or  gall  stones. 

If  the  incision  in  this  operation  is  to  be  in  the  median  line  it  is  besl 
to  extend  it  above  the  umbilicus  a  distance  of  one  or  two  inches,  to  excise 
the  umbilicus  entirely,  to  split  the  fascia  of  the  recti  muscles  toward  the 
median  line  and  then  to  close  the  abdominal  wound  throughout  as  though 
there  had  been  no  hernia. 

If  the  operation  is  for  the  removal  of  the  appendix  or  gall  stones  it 
is  well  to  make  the  incision  through  the  right  rectus  abdominis  muscle, 
then  the  inner  edge  of  the  abdominal  wall  can  be  everted.  If  there  is  ad- 
herent omentum  in  the  hernial  sac  this  can  be  peeled  out  and  then  a  purse- 
string  suture  of  chromicized  catgut  passed  around  the  hernial  ring  with 
a  short  curved  needle  just  outside  of  the  abdominal  wall  and  tied  just 
tightly  enough  to  hold  the  edges  in  apposition.  A  second  similar  stitch  is 
applied  just  within  the  abdominal  wall  and  tied  in  the  same  manner. 

This  may  be  done  very  easily  except  in  patients  with  an  unusually 
thick  abdominal  wall.  The  method  is,  however,  applicable  only  to  herniae 
of  moderate  size. 

VENTRAL  HERNIA   FOLLOWING  ABDOMINAL  SURGERY. 

Type  of  Case. 

The  patient,  an  unmarried  woman  twenty-two  years  of  age,  an  office 
girl  by  occupation,  gives  the  following  history :  Uneventful  life  until  age 
of  eighteen,  when  she  had  an  acute  attack  of  appendicitis,  which  subsided 
under  treatment  but  recurred  every  few  months.  Two  years  ago  she  had 
an  operation  for  the  relief  of  this  condition  at  the  end  of  an  acute  at- 
tack. The  wound  suppurated  and  healed  in  time  by  granulation.  The 
patient  has  been  free  from  acute  pain  since  that  time,  but  has  suffered 
from  severe  gaseous  distension  of  the  abdomen,  from  digestive  disturb- 
ances and  from  constipation.  The  scar  began  to  broaden  soon  after  the 
patient  returned  to  her  work  and  shortly  afterwards  she  noticed  a  distinct 
bulging  of  the  abdominal  wall  at  the  point  of  the  scar.  This  portion  of 
the  abdominal  wall  has  become  constantly  thinner  and  the  bulging  has  in- 
creased. 


PLATE  LVI. 

McBuRNEY's  INCISION. 

Represents  McBurney's  incision,  which  extends  parallel  with  the  fibres  of  the 
external  oblique  abdominal  muscle,  (a)  separating  its  fibres  without  cutting  them, 
then  separating  the  fibres  of  the  internal  oblique  muscle,  (b)  again  without  cutting 
its  fibres  and  extending  through  the  transversalis  fascia  and  peritoneum  (c)  in  the 
same  direction. 


Fig.  18. 

VENTRAL  HERNIA  FOLLOWING  APPENDICITIS  OPERATION. 

Represents  an  incision  through  all  the  tissues  of  the  abdominal  wall  parallel  with 
Poupart's  ligament,  separating  the  fibres  of  the  external  oblique  abdominal  muscle, 
(a)  but  cutting  the  fibres  of  the  internal  oblique  abdominal  muscle  (b)  at  right 
angles  and  extending  through  the  transversalis  fascia  and  peritoneum  (c)  in  the 
same  direction. 

The  internal  oblique  abdominal  muscle   (b)    is  by  far  the  thickest  layer. 


PLATE  LVII. 

CLOSURE  OF  ABDOMINAL   WOUND. 

Represents  the  manner  of  applying  sutures  in  closing  an  abdominal  incision  in  the 
median  line;  (a)  representing  the  deep  strong  fascia  composed  of  the  aponeurosis 
of  the  external  oblique  abdominal  muscles;  (b)  the  rectus  abclominis  muscle,  and  (c) 
the  transversalis  fascia  and  peritoneum. 


GENERAL    SURGERY    OF    THE    ABDOMEN  427 

There  is  a  scar  ten  centimeters  in  length  and  five  centimeters  wide, 
extending  parallel  with  Poupart's  ligament  about  half-way  between  the 
anterior  superior  spine  of  the  ilium  and  the  umbilicus.  The  tissue  is  so 
thin  that  the  motion  of  the  intestines  can  readily  be  distinguished  through 
it.  Upon  pressing  the  fingers  against  this  tissue  one  may  readily  feel  a 
definite  ledge  composed  of  the  abdominal  muscles  on  either  side,  and  the 
intestines  can  be  readily  felt  behind  this  thin  structure.  There  is  a  strong 
impulse  upon  coughing.  The  scar  is  very  tender  upon  pressure. 

Etiology. 

In  this  instance  there  had  beer!  an  abdominal  section  for  the  removal 
of  the  appendix.  The  incision  had  been  made  parallel  with  the  fibers  of  the 
external  oblique  abdominal  muscle,  then  it  had  been  carried  through  the 
internal  oblique,  the  transversalis  fascia  and  peritoneum. 

All  of  these  layers  had  been  united  after  the  operation,  but  the  sup- 
puration which  followed  prevented  primary  union  and  consequently  there 
was  a  union  between  the  edges  of  all  the  layers  involved  on  each  side  of 
the  line  of  incision  and  the  edges  thus  formed  were  united  by  a  mass  of 
cicatricial  tissue.  This  is  the  least  stable  of  all  tissues  and  consequently 
it  began  to  stretch  very  soon  after  the  patient  left  her  bed,  becoming  more 
and  more  thinned  out  from  day  to  day  and  permitting  the  intra-abdominal 
organs  to  protrude,  forming  a  ventral  hernia. 

There  is  another  factor  in  this  case  which  favored  the  formation  of 
a  ventral  hernia.  The  incision  was  parallel  with  the  fibers  of  the  external 
oblique  abdominal  muscle  and  consequently  none  of  the  fibers  of  this 
muscle  had  to  be  severed,  as  they  were  simply  split  longitudinally.  Had 
the  internal  oblique  abdominal  muscle  been  likewise  split,  as  shown  in 
plate,  the  two  edges  would  have  been  drawn  closely  together  as  a  result 
of  their  own  contraction,  and  the  lines  of  incision  through  the  two  mus- 
cular layers,  being  at  right  angles  to  each  other,  a  hernia  would  not  have 
developed,  even  though  the  wound  had  not  united  primarily. 

In  this  case  the  conditions  were  quite  different,  the  fibers  of  the  in- 
ternal oblique  abdominal  muscle  being  cut  at  right  angles,  the  edges  of 
the  wound  were  drawn  farther  and  farther  apart  with  each  contraction  of 
this  muscle  as  soon  as  primary  union  of  the  cut  ends  became  impossible 
on  account  of  suppuration.  Moreover,  these  ends  became  adherent  to  the 
edges  of  the  wound  in  the  external  oblique  abdominal  muscle  and  over- 
came the  tendency  these  edges  naturally  show  to  remain  parallel  and  in 
close  apposition. 

Indications  for  Operation. 

In  most  cases  of  ventral  hernia  following  abdominal  section  there  is 
no  definite  ring,  the  opening  being  wide ;  there  is  consequently  no  danger 
from  strangulation.  There  is,  however,  the  constant  feeling  of  insecurity 
and  weakness  in  the  abdominal  wall  which  prevents  the  patient  from  per- 
forming the  duties,  or  indulging  in  the  pastimes,  of  persons  in  health,  and 
as  the  tissues  become  thinner  and  thinner,  there  is  really  some  risk  of  hav- 
ing them  give  way  entirely. 

Moreover,  the  digestive  disturbances  of  which  such  patients  com- 
plain are  due  partly  to  the  fact  that  there  are  usually  adhesions  between 
the  intestines  and  omentum  and  the  scar  which  interfere  with  the  passage 
of  food  and  gases  through  the  portion  of  the  alimentary  canal  thus  im- 
paired. 


428  GENERAL    SURGERY    OF    THE    ABDOMEN 

When  the  protrusion  is  so  great  as  above  described,  and  cannot  be 
comfortably  retained  by  means  of  a  bandage,  there  is  a  sufficient  amount 
of  mechanical  obstruction  to  the  intestines  from  their  crowding  into  this 
pouch  to  account  for  the  digestive  disturbances.  For  these  reasons  it  seems 
wise  to  advise  operative  treatment,  especially  in  young  patients. 

Operative  Technique. 

We  first  make  an  incision  surrounding  all  of  the  scar  tissue,  because 
this  is  of  no  value  in  securing  a  permanent  cure  of  the  hernia  and  its  re- 
moval is  of  importance  from  a  cosmetic  standpoint. 

In  these  hernise,  as  in  umbilical,  fhe  adhesions  of  omentum  or  intestine 
are  likely  to  be  to  the  most  prominent  portion  of  the  hernial  protrusion  or 
to  the  edge  of  the  hernial  ring,  which  in  these  cases  is  so  large  as  scarcely 
to  deserve  this  name,  or  to  both  of  these  portions. 

The  operation  is  greatly  facilitated  by  making  the  incision  through  the 
peritoneum  at  a  point  where  there  are  no  adhesions.  This  may  usually  be 
accomplished  by  choosing  a  location  half-way  between  the  two  points  just 
mentioned. 

A  further  aid  is  found  in  lifting  up  the  tissues  with  two  dissecting 
forceps,  one  in  the  hand  of  an  assistant,  the  other  in  the  surgeon's  hand, 
and  cutting  between. 

As  soon  as  the  peritoneal  cavity  has  been  opened,  all  adhesions  are 
carefully  separated  in  a  systematic  manner.  If  abrasion  occurs  upon  the 
serous  surface  of  an  intestine  this  is  at  once  covered  with  one  or  more 
Lembert  stitches.  Should  the  omentum  be  matted  together  or  appear  in 
irregular  bunches  or  strands  these  are  ligated  and  cut  away.  Then  the 
intestines  and  omentum  are  replaced  into  the  abdominal  cavity  and  cov- 
ered with  a  broad  pad  of  sterilized  gauze,  moistened  with  warm  normal 
salt  solution. 

It  now  becomes  necessary  to  make  a  careful  dissection  of  the  edges 
of  the  wound,  in  order  to  lay  bare  each  one  of  the  layers  of  tissue.  This 
is  possible  even  in  cases  in  which  the  hernia  has  existed  for  a  number  of 
years. 

We  first  come  to  the  edges  of  the  incision  in  the  external  oblique  ab- 
dominal muscle  and  its  fascia,  then  we  encounter  the  fibers  of  the  internal 
oblique,  cut  at  right  angles  and  greatly  retracted,  and  lastly  upon  the  trans- 
versalis  fascia  and  peritoneum  combined.  All  of  these  layers  are  shown 
in  Fig.  18.  We  have  found  that  a  hernia  in  which  all  the  layers  have  been 
carefully  dissected  out  in  this  manner  may  be  closed  with  the  same  de- 
gree of  certainty,  as  regards  permanency  of  cure,  as  an  ordinary  laparoto- 
my  wound. 

A  row  of  silkworm  gut  sutures  is  now  inserted,  but  not  tied,  as  in- 
dicated in  Fig.  18.  The  stitches  are  placed  about  three-fourths  of  an  inch 
apart  and  grasp  each  layer  down  to,  but  not  through,  the  peritoneum.  In 
this  case  we  take  especial  care  to  draw  the  internal  oblique  abdominal 
muscle  forward,  as  shown  in  Fig.  18,  with  dissecting  forceps  in  order  to 
secure  a  deep  bite.  Each  layer  is  then  sutured  separately  with  a  con- 
tinuous catgut  stitch.  For  this  purpose  we  prefer  to  utilize  fine  chromi- 
cized  catgut,  No.  i,  threaded  double.  This  gives  the  suture  the  same 
strength  as  a  heavier  catgut  used  single  and  has  the  advantage  that  it  does 
not  twist  nor  become  unthreaded,  and,  theoretically  at  least,  it  offers  more 
favorable  conditions  for  absorption  when  it  has  accomplished  its  purpose. 


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GENERAL  SURGERY  OF  THE  ABDOMEN  435 

After  each  layer  has  been  sutured  carefully,  the  silkworm  gut  sutures 
are  tied  over  all.  We  believe  that  it  is  most  important  never  to  draw  any 
of  these  stitches  too  tightly  for  fear  of  causing  pressure  necrosis. 

A  narrow  pad  of  sterile  gauze  is  laid  upon  the  wound  and  then  the 
abdominal  wall  is  supported  with  two  straps  of  rubber  adhesive  plaster, 
at  least  two  inches  wide,  in  order  to  relieve  the  tension  upon  the  sutures. 

Principles  of  Cure. 

It  does  not  matter  in  what  portion  of  the  abdominal  wall  the  ventral 
hernia  following  an  abdominal  section  may  occur,  the  principles  concerned 
in  its  closure  are  always  the  same.  The  cicatricial  tissue  is  carefully  ex- 
cised, the  different  anatomical  layers  are  dissected  out  and  then  united  with 
deep  silkworm  gut  sutures,  while  each  layer  is  united  separately  with 
buried  sutures  of  chromicized  catgut  which  may  be  applied  in  continued  or 
interrupted  form. 

As  most  of  these  hernias  occur  either  after  appendicitis  operations  in 
the  right  inguinal  region,  or  in  the  median  line  between  the  umbilicus  and 
the  pubis,  we  also  illustrate  the  operation  in  the  latter  variety. 

In  this  position  our  dissection  must  expose  the  deep  fascia  composed 
of  the  aponeurosis  of  the  external  and  internal  oblique  abdominal  muscles, 
the  rectus  abdominis  muscle  on  either  side  and  the  transversalis  fascia  and 
peritoneum  which  are  closely  united. 

In  Plate  LVII  these  layers  are  shown,  the  silkworm  gut  stitches  being 
in  place  but  not  tied.  The  peritoneum  and  transversalis  fascia  have  been 
united  by  means  of  a  continuous  catgut  suture  passing  over  the  silkworm 
gut  sutures  so  that  the  latter  when  tied  will  bring  up  the  peritoneum  and 
thus  prevent  the  formation  of  dead  spaces  between  this  and  the  posterior 
surface  of  the  recti-muscles. 

The  interrupted  stitches  have  been  passed  through  the  recti  muscles 
in  the  upper  part  of  the  wound  and  tied  and  two  others  have  been  inserted 
in  the  lower  part  of  the  wound  and  left  untied  in  order  to  show  the  deeper 
stitches. 

The  deep  fascia,  composed  of  the  aponeurosis  of  the  internal  and  ex- 
ternal oblique  abdominal  muscle,  which  is  the  most  important  layer,  will  be 
carefully  sutured  over  this,  as  shown  in  Plate  LXI,  and  then  the  deep  silk- 
worm gut  sutures  will  be  tied  and  a  row  of  superficial  sutures  applied  for 
coaptation  of  the  skin,  as  shown  in  Plate  LXII. 

A  similar  dressing  will  be  applied  as  described  above  and  the  abdominal 
walls  will  be  supported  with  rubber  adhesive  plaster  as  before. 

HERNIA  OF  THE  LINEA  ALBA. 
Typical  Case. 

A  gardener  by  occupation,  forty-six  years  of  age,  gives  the  following 
history:  He  has  always  been  in  good  health,  with  the  exception  of  having 
had  an  attack  of  mountain  fever  lasting  ten  weeks,  from  which  he  suffered 
twenty  years  ago. 

He  does  not  remember  having  suffered  any  injury,  but  he  has  had  a 
number  of  periods  of  intoxication  lasting  for  several  days  at  a  time,  during 
which  he  might  easily  have  sustained  some  injury  without  knowing  it.  Six 
years  ago  he  noticed  a  small  swelling  in  the  median  line  half-way  between 
the  end  of  the  sternum  and  the  umbilicus.  This  has  increased  steadily  until 
it  has  attained  the  size  of  a  hen's  egg.  Usually  he  has  had  simply  a  feeling 


436  GENERAL    SURGERY    OF    THE    ABDOMEN 

of  weight  in  this  swelling,  but  occasionally  it  is  quite  painful  for  several 
days.  There  is  a  slight  decrease  in  the  size  of  the  swelling  at  night  and  a 
slight  increase  when  working  hard. 

Patient  is  well  nourished,  thoracic  and  abdominal  organs  normal,  ap- 
petite good,  bowels  constipated.  Two  inches  above  the  umbilicus,  in  the 
median  line,  there  is  a  swelling  as  large  as  a  hen's  egg,  not  painful  on  pres- 
sure, semi-fluctuating,  no  impulse  upon  coughing,  not  reducible  upon  pres- 
sure. In  all  other  respects  the  physical  examination  has  resulted  negatively. 

Judging  from  the  consistency  of  the  tumor,  from  its  oval,  slightly 
lobulated  form,  and  its  subcutaneous  location,  it  is  likely  that  it  is  composed 
of  fatty  tissue.  It  may  consequently  be  a  lipoma.  Were  there  a  history  of 
traumatism  immediately  preceding  its  appearance,  or  were  there  an  impulse 
upon  coughing,  we  could  make  a  positive  diagnosis  of  a  hernia  of  the  linea 
alba. 
Differential  Diagnosis. 

There  are  certain  peculiarities  in  this  case  which  point  distinctly  to  the 
latter  diagnosis : 

(1)  There  has  been  a  disturbance  of  the  stomach  since  the  appearance 
of  the  swelling,  which  is  due  in  many  cases  of  hernia  of  the  linea  alba  to 
the  fact  that  the  adherent  omentum  interferes  with  the  normal  motility  of 
the  stomach.     The  opening  in  the  linea  alba  is  frequently  so  small  that  an 
impulse  upon  coughing  is  not  possible.     This  is  still  further  interfered  with 
by  the  extensive  adhesions  of  the  omentum  to  the  hernial  sac,  which  is  fre- 
quently not  a  true  sac  composed  of  peritoneum  and  transversalis  fascia,  but 
simply  a  space  in  the  ruptured  tissues.     This  disturbance  is  sometimes  so 
great  that  the  patient  is  entirely  disabled. 

(2)  The  tumor  varies  in  size,  decreasing  a  little  at  night  and  increas- 
ing perceptibly  upon  making  severe  exertion  for  a  considerable  time,  as  upon 
working  very  hard.  Although  there  is  no  impulse  upon  coughing  or  straining 
it  seems  that  more  of  the  tissue  of  the  omentum  becomes   forced  through 
the  small  hernial  opening  when  there  is  long-continued  abnormal  intra-ab- 
dominal  pressure  than  when  this  is  normal. 

(3)  The  swelling  becomes  painful  at  irregular  intervals,  especially  when 
the  patient  engages  in  hard  work.     We  have  repeatedly  seen  strong,  other- 
wise perfectly  healthy  men  entirely  disabled  for  work  by  the  pain  resulting 
from  a  hernia  in  this  region,  so  small  that  it  had   escaped  the  notice  of 
physicians  and  surgeons  for  years,  the  patient  not  taking  it  to  be  of  sufficient 
importance  to  require  their  attention. 

(4)  The  swelling  usually  appears  suddenly  after  an  injury,  such  as  a 
sharp  blow  upon  the  linea  alba. 

Considering  all  of  these  facts  it  seems  likely  that  this  is  a  hernia  of 
the  linea  alba,  although  we  cannot  be  absolutely  positive  in  our  diagnosis 
until  the  mass  has  been  exposed. 

Etiology. 

In  this  case  the  etiology  is  not  very  clear  on  account  of  the  fact  that  it 
is  likely  the  patient's  powers  of  observation  were  greatly  impaired  at  the 
time  at  which  the  condition  was  produced. 

Indications  for  Operation. 

The  amount  of  suffering  is  not  sufficient  to  disable  the  patient  from 
performing  his  work,  but  he  suffers  from  gastric  disturbances  and  from 


PLATE  LXI. 

CLOSURE  OF   AUUOMINAL    WOUND. 

Represents  the  abdominal  wound  in  the  median  line  with  each  layer  sutured  sepa- 
rately, but  the  deep  silkworm  gut  sutures  still  untied;  (a)  represents  the  strong  deep 
fascia  composed  of  the  aponeurosis  of  the  internal  and  external  oblique  abdominal 
muscles  upon  which  the  permanency  of  the  closure  and  the  absence  of  post-operative 
hernia  deoends. 


PLATE  LXII. 

CLOSURE  OF  ABDOMINAL  WOUND. 

Represents  the  deep  silkworm  gut  sutures  tied  loosely  so  as  to  avokl  pressure 
necrosis  and  a  continuous  coaptation  stitch  for  the  accurate  adjustment  of  the  edges 
of  the  skin. 


GENERAL    SURGERY    OF    THE    ABDOMEN  441 

pain  in  the  region  of  the  swelling  whenever  he  labors  hard,  and  the  periods 
of  acute  irritation  are  becoming  more  numerous,  and  the  extent  of  the  irri- 
tation more  severe  constantly.  Moreover,  the  swelling  is  becoming  more 
and  more  sensitive  to  pressure  from  the  clothing. 

Were  it  possible  to  reduce  this  swelling  into  the  abdominal  cavity  its 
retention  by  means  of  a  truss  might  be  considered,  but  experience  has  shown 
that  this  would  not  succeed. 

The  patient  is  not  in  any  immediate  danger,  because  the  opening  is  too 
high  in  the  median  line  to  permit  the  protrusion  of  a  portion  of  the  small 
intestine,  and  it  is  too  small  to  engage  either  the  stomach  or  the  transverse 
colon.  There  is  consequently  no  danger  of  strangulation. 

The  patient  is  familiar  with  all  of  these  facts  and  has  chosen  the  opera- 
tion for  the  purpose  of  securing  relief  from  pain  and  to  increase  his  working 
capacity. 

The  preparatory  treatment  is  the  same  as  in  all  abdominal  sections. 
Were  the  patient  very  obese,  we  would  advise  treatment  for  the  relief  of  this 
encumbrance. 

Operative  Technique. 

A  longitudinal  incision  twelve  centimeters  in  length  is  made  over  the 
most  prominent  portion  of  the  swelling,  through  the  skin  and  superficial 
fascia,  which  exposes  a  flattened,  oval  mass  as  large  as  a  hen's  egg.  Lifting 
up  the  edges  of  this  mass  the  finger  reaches  a  point  in  the  aponeurosis  form- 
ing the  linea  alba  which  is  defective.  At  this  point  the  latter  has  a  perfora- 
tion which  would  admit  two  fing-ers  were  it  not  occupied  by  a  projection  of 
the. fatty  swelling  which  we  have  exposed.  The  latter  is  lobulated,  quite 
vascular  and  is  slightly  adherent  to  the  surrounding  tissues.  It  is  not 
surrounded  by  a  true  hernial  sac.  It  has  consequently  come  through  in  the 
defect  in  the  abdominal  wall  and  we  have  before  us  a  hernia  of  the  linea 
alba,  and  the  fatty  mass  is  composed  of  omentum  which  has  been  forced 
out  of  the  peritoneal  cavity  through  this  opening. 

It  is  impossible  to  replace  the  omentum  into  the  peritoneal  cavity,  and 
if  it  were  it  would  not  be  desirable  to  do  so  because  it  has  been  so  completely 
changed  from  a  thin,  delicate,  protecting  sheet  into  a  clumsy  mass,  that  it 
would  probably  give  rise  to  irritation  were  it  replaced.  We  will  conse- 
quently transfix  the  narrowed  portion,  at  the  point  where  it  issues  from  the 
opening  in  the  aponeurosis,  with  a  double  catgut  ligature,  tie  it  in  halves, 
cut  away  the  mass  a  sufficient  distance  outside  of  the  ligature  to  prevent 
slipping,  and  drop  the  stump  into  the  abdominal  cavity. 

It  frequently  happens  that  the  fat  contained  in  a  hernia  of  the  linea 
alba  is  partly  or  entirely  composed  of  pre-peritoneal  fat  instead  of  omentum. 
These  patients  suffer  even  greater  pain  than  those  in  which  the  mass  is 
composed  entirely  of  omentum.  When  this  mass  is  removed  the  pedicle 
is  simply  reduced  through  the  hernial  opening  into  the  pre-peritoneal  space. 

The  remaining  steps  of  the  operation  vary  according  to  the  character 
of  the  opening.  If  this  is  small  and  circular,  and  if  its  edges  are  thick,  it 
is  probably  quite  as  unnecessary  to  do  anything  toward  closing  it  as  in 
femoral  hernia.  As  soon  as  the  ring  is  empty  it  will  close  spontaneously. 

If  the  opening  is  oblong  or  triangular  in  form  but  not  more  than  two 
or  three  centimeters  in  length  with  substantial  edges,  these  may  be  brought 
together  with  two  or  three  buried  chromicized  catgut  sutures.  If,  however, 
the  opening  is  oblong  and  its  edges  thin,  as  in  this  case,  it  is  likely  there 


442  GENERAL    SURGERY    OF    THE    ABDOMEN 

would  be  a  recurrence  unless  the  defect  were  repaired  in  a  more  substantial 
manner. 

In  order  to  secure  favorable  conditions  for  a  permanent  cure  in  these 
cases  it  is  necessary  to  carefully  expose  each  one  of  the  various  layers  com- 
posing the  abdominal  wall  at  this  point  and  then  to  close  the  wound  precisely 
in  the  manner  described  in  operations  for  ventral  hernia  following'  abdominal 
section  in  the  median  line.  The  anatomical  layers  in  this  portion  of  the 
linea  alba  from  without  inward  are  as  follows:  i,  skin;  2,  superficial  fascia; 
3,  fat ;  4,  strong  fascia  composed  of  the  aponeurosis  of  the  external  oblique 
abdominal  muscle  and  the  outer  half  of  the  fascia  of  the  internal  oblique ; 
5,  rectus  abdominis  muscle ;  6,  the  inner  half  of  the  fascia  of  the  internal 
oblique  abdominal  muscle;  7,  the  transversalis  fascia;  8,  peritoneum.  The 
last  three  layers  mentioned  are  usually  so  closely  united  with  each  other 
that  they  appear  as  one. 

Having  exposed  these  layers  we  close  the  wound  as  shown  in  Plates 
LYII  and  LXI. 

A  row  of  silkworm  gut  sutures  extending  through  all  the  layers  down 
to  the  peritoneum  are  inserted  but  not  tied.  Then  the  deepest  layer  com- 
posed of  peritoneum,  transversalis  fascia  and  the  inner  half  of  the  aponeu- 
rosis of  the  internal  oblique  abdominal  muscle  is  sutured  with  a  continuous 
catgut  suture.  Xow  the  recti  muscles  are  brought  together  by  means  of 
just  a  sufficient  number  of  interrupted  catgut  sutures  to  bring  them  in 
accurate  apposition.  The  strong,  deep  fascia,  upon  which  the  permanency 
of  the  cure  really  depends,  is  next  carefully  sutured  with  chromicized  cat- 
gut ;  and  then  the  deep  silkworm  gut  sutures  are  tied  and,  if  necessary,  a 
row  of  coaptation  stitches  is  applied  to  adjust  the  edges  of  tne  skin. 

In  connection  with  this  case  we  wish  to  direct  attention  particularly  to 
the  diagnosis  of  these  troubles. 

They  are  somewhat  rare  and  almost  never  diagnosed  until  they  have 
suffered  for  many  years.  In  the  meantime  they  usually  go  from  one  physi- 
cian to  another,  receiving  treatment  alternately  for  the  relief  of  gastric 
disturbances  and  neurasthenia. 

HERNIA  IN   CHILDREN. 

Example. 

A  boy.  twenty  months  of  age,  comes  with  the  following  history :  He 
has  always  been  well  and  strong  since  birth  and  none  of  his  functions  have 
been  impaired.  There  is  a  vague  history  of  a  fall  two  months  ago,  but 
nothing  definite  can  be  determined  in  this  respect.  It  is  quitely  likely  that 
the  mother  imagines  this  from  the  fact  that  she  feels  compelled  to  account 
for  the  child's  condition  in  some  way. 

Six  months  ago  the  mother  noticed  a  swelling  in  the  region  of  the  left 
inguinal  canal  extending  into  the  scrotum  on  that  side.  This  swelling 
decreases  in  size  when  the  child  is  in  bed,  but  cannot  be  reduced  while  he 
is  awake.  The  protrusion  increases  when  the  child  cries.  There  is  an 
abundance  of  fat  in  the  subcutaneous  tissues  and  it  is  difficult  to  determine 
whether  the  mass  fluctuates  upon  palpation.  An  attempt  has  been  made  to 
apply  a  truss,  but  the  child  screamed  incessantly  when  this  was  in  place,  so 
that  it  had  to  be  removed  directly.  The  child  is  otherwise  normal,  with  the 
exception  of  having  an  adherent  prepuce. 


GENERAL    SURGERY    OF    THE    ABDOMEN  443 

Differential  Diagnosis. 

It  is  often  difficult  to  make  a  positive  diagnosis  in  a  child  so  young  as 
this  one,  because  it  is  practically  impossible  to  keep  him  quiet  long  enough 
to  determine  the  conditions  present,  unless  he  is  anesthetized. 

Hydrocele  is  the  only  condition,  aside  from  hernia,  which  is  common 
in  children  of  this  age  and  causing  a  swelling  in  this  position.  In  one  case 
we  encountered  a  lymphangioma,  and  a  congenital  lipoma,  or  one  developing 
shortly  after  birth,  which  is  possible  in  this  location,  but  so  rare  that  it  really 
need  not  be  considered. 

Now  that  the  child  is  anesthetized,  we  find  that  the  swelling  can  be 
reduced  into  the  abdominal  cavity  through  the  inguinal  canal,  but  as  soon 
as  the  pressure  is  released  it  reappears  at  once.  There  is  also  the  sensation 
to  touch  of  reducing  a  mass  of  a  definite,  permanent  form  which  would  not 
be  the  case  were  the  swelling  composed  of  omentum  or  intestine  contained 
in  a  hernial  sac.  The  condition  present  must  consequently  be  an  irreducible 
hydrocele  of  the  cord. 
Etiology. 

In  this  patient  the  communication  between  the  peritoneal  cavity  and  the 
tunica  vaginalis  evidently  remained  open  after  the  descent  of  the  testicle 
and  gave  rise  to  a  congenital  hernia.  At  some  time  later  the  upper  end  of  this 
hernial  sac  closed  by  adhesion  of  its  walls,  and  then  its  serous  lining,  instead 
of  becoming  adherent  to  the  tissues  of  the  spermatic  cord  and  thus  bringing 
about  a  spontaneous  cure,  secreted  fluid  and  this  caused  the  distension  of 
this  sac.  Being  located  in  the  inguinal  canal  the  latter  cannot  close,  hence 
the  impulse  upon  coughing  or  straining. 

Indications  for  Operation. 

So  long  as  the  inguinal  canal  is  distended  by  this  pouch  filled  with  fluid 
it  is  impossible  for  it  to  close  and  the  development  of  the  child  cannot 
proceed  normally.  The  mass  cannot  be  reduced  into  the  peritoneal  cavity 
thus  leaving  the  canal  free  to  close,  neither  can  it  be  withdrawn  downward. 
It  is  consequently  necessary  to  resort  to  some  operative  measure  for  the 
relief  of  the  condition.  This  can  be  accomplished  by  withdrawing  the  fluid 
by  means  of  a  cannula,  but  this  would  probably  not  secure  permanent  relief 
because  the  serous  fluid  would  re-form  unless  some  irritating  substance  was 
injected  which  would  result  in  a  sufficient  amount  of  aseptic  inflammation 
to  cause  the  surfaces  to  adhere.  For  this  purpose  a  few  drops  of  ninety-five 
per  cent  solution  of  carbolic  acid  has  been  injected,  or  a  larger  quantity  of 
five  per  cent  solution  of  the  same  substance,  or  a  few  drops  of  tincture  of 
iodine.  None  of  these  substances  is,  however,  certain  to  accomplish  the  end 
desired. and  none  of  them  entirely  harmless.  We  will  consequently  choose 
a  method  which  is  not  connected  with  more  danger  and  which  will  result  in 
a  permanent  cure. 

Technique  of  Operation. 

An  incision  is  made  over  the  most  prominent  portion  of  the  swelling 
parallel  with  the  inguinal  canal  and  down  to  the  hernial  sac.  It  is  now 
apparent  that  the  sac  is  distended  with  fluid.  We  incise  it  and  permit  the 
fluid  to  escape.  We  find  a  smooth  sac  containing  nothing  but  about  thirty 
cubic  centimeters  of  a  clear  fluid.  The  sac  is  easily  separated  from  the  sur- 
rounding tissues.  At  its  upper  end  it  is  found  closed  by  means  of  scar 
tissue  which  has  united  its  walls.  It  is  withdrawn  from  the  inguinal  canal 


444  GENERAL    SURGERY    OF    THE    ABDOMEN 

a  little  further,  then  transfixed  with  a  needle  threaded  with  catgut  and  tied. 
Then  the  sac  is  cut  away,  care  being  taken  to  leave  a  sufficient  amount  of 
tissue  beyond  the  ligature  to  prevent  slipping.  The  stump  is  permitted  to 
retract  within  the  abdominal  cavity.  No  attempt  is  made  to  close  the 
inguinal  canal,  because  this  occurs  spontaneously  in  children  as  soon  as  the 
sac  is  removed.  Suturing  the  skin  completes  the  operation. 

Carefully  compiled  statistics  have  shown  that  of  all  the  hernias  encoun- 
tered in  the  adult  less  than  five  per  cent  have  existed  since  childhood,  and 
also  that  of  all  children  under  six  years  of  age  suffering  from  hernia  seventy- 
three  per  cent  will  heal  spontaneously,  without  any  form  of  treatment,  before 
the  age  of  thirteen,  consequently  .the  relative  number  of  hernise  in  children 
requiring  operative  treatment  must  be  very  small. 

Conditions  Favoring  Spontaneous  Cure. 

Spontaneous  cure  is  accomplished,  ( i )  By  the  late  closure  of  the 
inguinal  canal,  which  should  have  occurred  before  birth;  (2)  By  the  broad- 
ening of  the  pelvis.  The  parietal  peritoneum  enlarges  at  the  expense  of 
the  mesentery ;  the  latter  being  thus  shortened  prevents  the  entrance  of  the 
intestines  into  the  inguinal  canal;  (3)  By  the  displacement  of  the  internal 
abdominal  ring  with  the  growth  of  the  child  ;  (4)  With  the  growth  of  the 
child  a  number  of  the  predisposing  causes  are  eliminated.  These  are : 

Predisposing  Conditions  to  Overcome. 

(a.)  Abnormal  intra-abdominal  pressure. — There  can  be  no  doubt 
that  the  most  important  direct  cause  of  hernias  in  children  is  an  abnormal 
intra-abdominal  pressure.  This  may  be  due:  i.  To  gaseous  distension  of 
the  stomach  and  bowels,  caused  by  faulty  feeding  and  consequent  indiges- 
tion ;  2,  To  great  pressure  exerted  during  the  act  of  defecation,  on  account 
of  constipation.  3,  To  the  same  condition  due  to  obstruction  on  account  of 
phimosis.  4,  To  severe  vomiting.  5,  To  long-continued  coughing.  In  con- 
nection with  all  of  these  conditions,  it  is  to  be  remembered  that  children 
with  digestive  disturbances  necessarily  suffer  much  from  pain,  and  the 
exertion  incident  to  crying  will  greatly  increase  the  existing  abnormal  intra- 
abdominal  pressure.  In  order  to  quiet  the  child  the  mother  will  nurse  it  at 
irregular  intervals  and  this  will  again  increase  the  digestive  disorder,  and 
this,  in  turn,  the  intra-abdominal  pressure  and  pain. 

(b. )  Increased  intra-abdominal  pressure  due  to  coughing. — \Ye  have  ob- 
served cases  in  which  the  herniae  healed  regularly  during  the  summer 
months,  but  reappeared  in  the  autumn  as  soon  as  the  children  acquired 
coughs,  which  lasted  almost  all  winter.  By  the  time  spring  arrived  the 
hernia?  had  attained  considerable  size,  only  to  heal  again  during  the  summer 
while  the  patients  were  free  from  coughs.  By  placing  these  children  in  bed 
and  elevating  the  lower  end  sufficiently  to  make  an  angle  of  twenty  degrees 
and  giving  them  remedies  to  relieve  the  cough,  the  hernise  disappeared  within 
six  weeks.  Then  advising  the  mothers  to  give  the  children  cold  baths  every 
day  and  to  bring  them  for  inspection  often  enough  to  keep  the  condition 
under  control,  and  giving  them  codliver  oil  and  malt  extract  as  soon  as  the 
cold  weather  appeared,  they  went  through  the  next  winter  without  coughs 
and  consequently  without  a  recurrence  of  the  hernise.  In  the  same  manner 
children  who  are  suffering  from  obstruction  to  the  upper  air-passages,  on 
account  of  enlarged  tonsils,  nasal  adenoids  or  polypi  and  consequent  condi- 
tions, will  rapidly  recover  from  their  herniae  if  these  conditions  are  relieved 
by  proper  treatment. 


GENERAL    SURGERY    OF    THE    ABDOMEN  445 

(c.)  Increased  pressure  due  to  gaseous  distension. — It  is  very  usual 
for  the  children  who  are  brought  into  the  hospitals  for  the  treatment  of 
hernia  to  have  greatly  distended  abdomens,  due  to  digestive  disorders  result- 
ing in  gaseous  distension  of  the  stomach  and  intestines.  If  this  occurs  in 
nursing  infants  the  mother  should  be  instructed  to  nurse  the  child  at  regular 
times.  Her  own  habits  and  diet  should  also  be  regulated.  If  the  child  is 
constipated  this  condition  should  be  relieved.  Aside  from  this  the  mother 
must  be  instructed  never  to  carry  the  child,  because  she  will  not  follow  the 
advice  of  keeping  it  in  the  inverted  position  and,  consequently,  will  increase 
the  intra-abdominal  pressure  whenever  she  picks  up  the  infant.  It  should 
sleep  in  a  separate  bed  with  the  lower  end  elevated  sufficiently  to  make  an 
angle  with  the  floor  of  about  twenty  or  thirty  degrees.  This  will  keep  the 
hernial  sac  empty  of  intestines  and  omentum  and  will  very  greatly  assist  in 
the  obliteration  of  the  hernia.  If  the  mother's  milk  continues  to  give  rise  to 
indigestion,  notwithstanding  every  precaution  available  for  making  it  whole- 
some, it  is  often  best  to  place  the  child  partly  or  wholly  on  artificial  food,  at 
least  for  a  time.  Above  all  things,  however,  it  is  important  to  impress  the 
mother  with  the  necessity  of  being  regular  in  feeding  the  child  and  to  again 
place  it  in  its  bed  as  soon  as  it  has  been  nourished,  or,  better  still,  to  lean 
over  the  child's  bed  and  nurse  it  without  disturbing  its  partly  inverted 
position. 

\Ye  have  repeatedly  placed  these  children  in  the  hospital  and  sent  the 
mother,  who  was  exhausted  from  overwork  and  care  of  the  sick  child,  home 
to  rest,  permitting  her  to  come  to  the  hospital  morning,  noon  and  night  to 
nurse  the  child.  After  the  first  day  or  two  the  mother  becomes  rested,  her 
journeys  to  and  from  the  hospital  compel  her  to  be  out  of  doors,  and  the 
fact  that  she  is  relieved  of  the  care  of  the  child  gives  her  the  necessary  rest 
and  sleep.  In  the  meantime  her  milk  improves,  the  child  becomes  accus- 
tomed to  lie  quietly  in  bed  and  to  take  its  nourishment  regularly,  its  digestion 
improves,  the  gaseous  distension  disappears,  and  with  it  the  abnormal  intra- 
abdominal  pressure,  which  is  still  further  relieved  because  the  child  sleeps 
most  of  the  time  and  seldom  cries.  After  the  child  has  been  in  the  partly 
inverted  position  for  a  few  days  the  hernial  sac  remains  empty  so  long  as 
this  position  is  continued,  even  if  he  strains  and  cries. 

( cl. )  Increased  infra-abdominal  pressure  during  defecation,  due  to 
constipation. — Children  suffering  from  hernia  should  not  be  allowed  to 
become  constipated,  because  the  increased  intra-abdominal  pressure  neces- 
sary to  accomplish  the  evacuation  of  the  bowels  in  constipation  is  in  itself 
sufficient  to  prevent  a  hernial  aperture  from  closing.  This  is  one  of  the 
most  common  causes  of  hernia  in  children,  and  one  of  the  easiest  to  be 
eliminated. 

(e.)  Increased  intra-abdominal  pressure  due  to  obstruction  to  the 
passage  of  urine  as  a  result  of  phimosis. — That  phimosis  is  a  frequent  cause 
of  hernia  in  children  is  plain  from  the  fact  of  the  greater  frequency  of 
umbilical  hernia  in  male  than  in  female  children.  The  greater  frequency 
of  inguinal  hernia  in  male  children  can  readily  be  accounted  for  by  the 
difference  in  the  anatomic  structures,  but  this  is  not  the  case  in  umbilical 
hernise,  which  is  also  shown  statistically  to  be  more  common  in  male  than 
in  female  children.  It  has  lately  been  suggested  that  phimosis  cannot  be  an 
important  cause  of  hernia  in  children,  because  if  this  were  the  case  the 
Jewish  nation  must  necessarily  be  much  freer  from  hernia  than  others. 
This,  is,  however,  not  the  case.  In  fact,  it  has  been  shown  by  statistics, 


44-6  GENERAL    SURGERY    OF    THE    ABDOMEN 

especially  in  Russia,  that  at  the  age  of  twenty  to  twenty-one  proportionally 
more  Jews  than  Christians  are  afflicted  with  hernia.  This,  however,  may  be 
explained  by  the  fact  that  the  Jews  are  more  subject  to  hereditary  diseases 
of  all  kinds,  on  account  of  the  system  of  intermarriage  in  families. 

If  the  phimosis  is  relieved,  either  by  circumcision  or  by  dilatation  of  the 
prepuce,  and  the  child  kept  in  bed  for  four  to  six  weeks  with  the  foot  of  the 
bed  elevated,  the  hernia  will  almost  invariably  be  cured.  During  the  same 
time  the  diet  and  the  bowels  must  be  carefully  regulated,  and  it  is  doubtful 
which  of  these  three  means  has  been  of  the  greatest  importance  in  producing 
a  cure.  It  is  surprising  how  rapidly  the  opening  will  contract  under  these 
conditions.  Moreover,  during  this  time  the  patient  acquires  regular  habits 
which  may  afterwards  be  easily  maintained  if  their  importance  is  explained 
to  the  mother,  and  especially  if  it  is  impressed  on  her  that  by  following  the 
directions,  which  will  naturally  appeal  to  her  on  account  of  their  simplicity 
and  reasonableness,  she  will  be  able  to  make  operative  treatment  unneces- 
sary. 

That  all  of  these  conditions  are  of  the  greatest  importance  may  be 
demonstrated  practically,  with  the  greatest  ease,  by  comparing  the  relative 
frequency  of  hernia  in  children  of  the  very  ignorant  poor,  of  the  intelligent 
poor,  and  of  the  well-to-do.  In  the  former  class,  after  the  child  is  weaned, 
but  little  attention  is  given  to  its  diet,  to  the  state  of  its  bowels,  and  to  the 
condition  of  the  prepuce  in  boys,  and  consequently  hernise  are  very  common, 
while  they  are  much  less  common  in  the  second,  and  still  less  in  the  third 
class. 

STRANGULATED    HERNIA    IN    CHILDREN. 

If  a  strangulated  hernia  in  a  child  cannot  be  easily  reduced,  under  com- 
plete anesthesia,  by  taxis,  the  child  being  held  in  the  inverted  position  during 
the  manipulations,  it  is  undoubtedly  wiser  to  relieve  the  danger  by  an  opera- 
tion, because  the  intestinal  wall  in  children  is  very  delicate  and  easily  injured 
by  taxis.  In  our  experience  the  hernial  opening  has  always  been  very  nar- 
row ;  still  we  have  always  succeeded  in  replacing  the  hernial  contents,  with- 
out enlarging  the  opening,  by  first  drawing  out  more  intestine  and  then 
gradually  replacing  it,  the  child  being  maintained  in  the  inverted  position. 
Technique. 

If  the  hernia  is  an  acquired  one,  which  is  not  common  in  children,  the 
sac  is  carefully  dissected  free  to  a  point  within  the  abdominal  cavity.  It  is 
then  ligated  and  removed  and  the  ligated  stump  permitted  to  retract  into  the 
peritoneal  cavity. 

If  the  hernia  is  congenital  it  is  best  to  dissect  up  the  neck  of  the  sac 
for  about  an  inch,  and  leave  the  portion  surrounding  the  testicle  to  form  a 
tunica  vaginalis,  while  the  upper  portion  is  carefully  dissected  up  to  a  point 
within  the  peritoneal  cavity ;  it  is  then  ligated,  the  superfluous  portion  is  cut 
away  and  the  stump  permitted  to  retract  into  the  peritoneal  cavity,  as  in 
case  of  the  acquired  hernia.  It  is  thus  only  necessary  to  close  the  skin  and 
the  opening  will  close  completely  in  from  four  to  six  weeks  if  the  child  is 
kept  in  bed  with  the  foot  of  the  bed  elevated. 

If  it  is  possible  to  reduce  a  strangulated  hernia  in  children  by  taxis,  the 
irritation,  caused  primarily  by  the  strangulation  and  secondarily  by  the 
manipulation,  seems  to  favor  closure  of  the  hernial  opening.  We  have 
repeatedly  seen  this  occur  within  six  weeks  if  the  child  was  kept  in  bed  in 
the  partly  inverted  position. 


GENERAL    SURGERY    OF    THE    ABDOMEN  447 

Unfavorable  Cases. 

The  most  unfavorable  cases  are  those  in  which  the  abdominal  walls 
are  congenitally  weak,  a  condition  which  seems  to  be  hereditary  in  many 
patients.  Again,  of  these  cases  those  in  which  there  are  three  distinct  areas 
of  weakness — the  abdomen  of  three  hills  described  by  Malgaigne — seem  to 
be  least  favorable  of  all.  In  this  class  surgical  treatment  may  become  neces- 
sary, and  here  it  is  well  to  perform  the  typical  Bassini  operation,  or  that 
described  by  Ferguson,  the  important  point  in  the  operation  being  to  secure 
an  accurate  closure  of  the  inguinal  canal  to  make  up  for  the  natural  defi- 
ciency in  the  tissues.  Two  precautions  should  be  borne  in  mind:  i,  The 
stitches  should  be  tied  very  loosely,  in  order  not  to  cause  pressure-necrosis 
of  the  already  weakened  tissues.  2,  The  tissues  of  the  cord  in  the  male 
should  be  manipulated  very  carefully  for  fear  of  causing  an  atrophy  of, 
or  preventing  the  full  development  of,  the  testicle.  This  is  especially 
important  in  these  cases  because  hernise  in  this  class  of  patients  are  very 
likely  to  be  double,  and  if  both  testicles  should  atrophy  the  patient  would 
be  permanently  injured.  In  this  class  frequently  no  truss  will  retain  the 
hernia. 

There  is  but  one  other  condition  which  justifies  the  operative  treatment 
of  hernia  in  children,  and  that  is  when,  on  account  of  adhesions,  the  hernia, 
although  not  strangulated,  is  still  irreducible.  In  this  class  a  truss  cannot 
be  worn  with  benefit,  because  it  presses  on  the  hernial  contents,  usually 
omentum,  instead  of  the  empty  canal;  moreover,  the  opening  not  being 
empty,  its  closure  is  necessarily  impossible  unless  the  adhesions  are  absorbed, 
which,  if  occurring  at  all,  necessarily  requires  a  long  period  of  time.  In 
this  variety  of  hernia,  unless  it  be  complicated  with  the  form  just  described, 
it  is  not  necessary  to  do  anything  further  than  in  case  of  strangulated  hernia. 
The  hernial  sac  being  removed,  the  opening  will  close  spontaneously. 

In  operation  for  relief  of  femoral  hernia  in  children  it  is  never  necessary 
to  do  anything  beyond  dissecting  out,  ligating  and  cutting  away  the  sac, 
permitting  the  stump  to  retract  into  the  peritoneal  cavity,  and  closing  the 
skin.  These  cases  are  exceedingly  rare.  We  have  never  seen  a  strangulated 
femoral  hernia  in  a  child,  and  only  once  an  irreducible  one  due  to  an  adherent 
omentum,  which  necessitated  an  operation. 

Use  of  Trusses. 

Too  much  stress  has  been  laid  upon  the  importance  of  trusses  in  the 
treatment,  and  too  little  on  removing  the  causes,  of  hernia  in  children. 

It  is  far  easier  to  retain  a  hernia  and  thus  encourage  the  closure  of  the 
hernial  opening,  by  first  relieving  the  abnormal  intra-abdominal  pressure 
and  then  applying  the  truss  simply  as  an  aid,  than  it  would  be  to  accomplish 
the  same  object  by  the  use  of  the  truss  alone. 

If  it  is  at  all  possible  it  is  always  best  to  place  the  child  in  bed  in  the 
inverted  position,  and  to  reduce  the  intra-abdominal  pressure  by  the  methods 
which  have  been  described,  before  making  use  of  a  truss  at  all.  Then,  if 
it  is  not  possible  to  maintain  this  position  sufficiently  long  to  obtain  a  cure 
it  is  well  to  apply  a  perfectly-fitting  truss. 

The  fact  of  using  a  truss  does  not  make  the  other  precautions  unneces- 
sary. The  child  should  still  be  cared  for  so  as  to  remove  intra-abdominal 
pressure  from  every  cause,  and  the  foot  of  its  bed  should  still  be  elevated 
in  order  to  make  use  of  gravity  in  keeping  the  hernia  empty  and  to  facilitate 
the  shortening  of  the  mesentery. 


44^  GENERAL    SURCiERY    OF    THE    ABDOMEN 

Pertinent  Conclusions. 

The  following  conclusions  seem  to  cover  the  treatment  of  hernia  in 
children : 

1.  The  development  of  hernise  in  children  is  favored  by:   (a)   faulty 
development  of  the  abdominal  wall;  (b)   insufficient  strength  in  the  tissues 
involved  in  closing  the  umbilical,  inguinal  or  femoral   openings;    (c)    ab- 
normal  intra-abdominal    pressure;    (d)    unclosed    condition    of    the    tunica 
vaginalis.  s 

2.  The  causes  (a)  and  (b)  are  likely  to  be  inherited. 

3.  The  abnormal  intra-abdominal  pressure  is  due:  (a)  to  gaseous  dis- 
tension resulting  from  improper  feeding;   (b)   to  the  exertion  necessary  to 
accomplish   defecation   in   case   of   chronic   constipation;    (c)    to   the   same 
exertion  necessary  to  evacuate  the  bladder  on  account  of  obstruction  due  to 
phimosis ;  (c)  to  severe,  long-continued  coughs. 

4.  A  large  majority  of  all  cases  of  hernia  in  children  will  heal  spon- 
taneously if  the  increased  intra-abdominal  pressure  is  relieved,  the  hernial 
sac  being  kept  empty. 

5.  This  may  be  accomplished  by  means   of   a   truss   or,   much   more 
rapidly,  in  inguinal  and  femoral  hernia,  by  placing  the  child  in  bed  with  the 
foot  of  the  bed  elevated,  the  time  required  usually  not  exceeding  six  weeks. 

6.  Children   with   a   tendency  to   the   formation   of   hernia   should   be 
guarded  against  developing  coughs. 

7.  Their  diet  should  be  given  at  regular  times  and  chosen  with  a  view 
to  avoiding  gaseous  distension. 

8.  Constipation  should  be  entirely  prevented. 

9.  In  case  of  boys,  phimosis  should  be  relieved,  if  present. 

10.  Badly-nourished  and  badly-cared-for  children  of  the  poor  should 
be  treated  in  hospitals,  being  placed  in  bed  in  the  inverted  position,   the 
cause  of  increased  intra-abdominal  pressure  being  removed  at  the  time  by 
proper  treatment. 

11.  Operation  is  indicated    (a)    in  strangulated  hernia;    (b)    in  irre- 
ducible hernia  due  to  adhesions;  (c)  in  case  the  opening  is  unusually  large 
in  a  free  hernia,  especially  if  the  condition  is  hereditary  and  the  hernia  can- 
not be  retained  by  means  of  a  truss;  (d)   in  reducible  hydrocele. 

12.  Except  in  class  c,  the  operation  should  consist  simply  in  carefully 
dissecting  out  the  sac,  ligating  it  within  the  abdominal  cavity,  cutting  away 
the  sac  and  permitting  the  stump  to  retract  within  the  abdominal  cavity,  and 
simply  closing  the  wound  in  the  skin. 

13.  The  recumbent  position,  with  the  foot  of  the  bed  elevated,  is  of 
very  great  importance  in  the  operative  as  well  as  in  the  non-operative  treat- 
ment of  herniae  in  children. 

14.  If  the  child  cannot  be  kept  in  this  position  sufficiently  long,  a  well- 
fitting  truss  should  be  worn  night  and  day  until  there  has  been  no  protrusion 
for  at  least  six  months,  at  the  same  time  the  necessary  precautions  being 
constantly  taken  to  guard  against  intra-abdominal  pressure  from  any  cause. 

HERNIA  IN  OLD  MEN. 

It  frequently  happens  that  a  male  patient  can  easily  retain  his  hernia  by 
means  of  a  truss  until  he  has  attained  the  age  of  about  sixty  years,  when 
he  is  no  longer  able  to  do  this,  and  consequently  seeks  relief  through  a 
surgical  operation. 


GENERAL    SURGERY    OF    THE    ABDOMEN  449 

He  may  have  grown  obese  or  his  tissues  may  have  become  soft  and 
less  able  to  resist  intra-abdominal  pressure,  but  there  is  an  important  factor 
in  the  increased  intra-abdominal  pressure  required  in  emptying  the  bladder 
on  account  of  an  obstruction  to  the  passage  of  the  urine,  caused  by  an 
enlarged  prostate  gland.  This  is  very  common  in  old  men. 

In  quite  a  large  proportion  there  will  be  a  rapid  reduction  in  the  size 
of  the  prostate  gland  if  either  a  vasectomy  or  an  orchidectomy  is  done. 
Both  of  these  operations  can  be  made  very  easily  in  connection  with  herni- 
otomy  without  increasing  the  danger  to  the  patient,  and  as  both  remove 
some  of  the  loose  tissue  in  the  inguinal  canal  they  favor  permanency  of  cure 
in  two  ways:  i,  by  making  the  union  between  the  layers  to  be  united  more 
perfect,  and  2,  by  decreasing,  indirectly,  the  excessive  intra-abdominal  pres- 
sure by  reducing  the  size  of  the  prostate  gland. 

In  many  of  these  cases  it  is  undoubtedly  best  to  perform  a  perineal 
prostatectomy  as  well  as  a  herniotomy.  If  the  patient's  general  condition  is 
good  both  of  these  operations  may  be  accomplished  at  the  same  time,  if  not, 
it  is  probably  best  to  make  a  herniotomy  together  with  an  orchidectomy  first, 
and  if  this  fails  to  produce  a  sufficient  atrophy  of  the  prostate  gland  to  per- 
form prostatectomy  later. 

If  the  prostatic  trouble  is  very  pronounced  so  that  the  patient  has  to 
get  up  several  times  during  the  night  and  strain  to  urinate,  it  is  well  to 
relieve  the  prostatic  obstruction  before  operating  upon  the  hernia,  for  the 
constant  straining  is  likely  to  interfere  with  a  perfect  healing  of  the  tissues 
thus  bringing  about  a  relapse  of  the  hernia. 

The  greatest  proportion  of  strangulation  occurs  in  patients  past  middle 
life.  It  is  not  uncommon  for  a  patient  to  have  a  hernia  for  forty  or  fifty 
years  that  has  always  been  easily  reducible,  and  then  become  suddenly 
strangulated.  In  the  majority  of  cases  the  hernial  opening  increases  in  size 
with  old  age,  and  the  protrusion  constantly  slips  outside  of  the  truss,  increas- 
ing the  patient's  discomfort  and  placing  him  in  constant  danger  of  strangu- 
lation. 

In  operating  upon  old  people  one  frequently  finds  that  the  conjoined 
tendon  has  been  almost  completely  obliterated.  When  this  condition  exists, 
it  is  well  to  transplant  the  cord  and  close  the  lower  angle  of  the  wound  as 
closely  as  possible.  When  the  obliteration  of  the  conjoined  tendon  is  very 
pronounced  this  lower  angle  can  be  closed  best  by  opening  the  sheath  of 
the  rectus  muscle  and  utilizing  that  muscle  in  the  closure,  after  the  method 
of  Bloodgood,  as  described  in  a  previous  section. 

STRANGULATED  HERNIA. 
Type  of  Case. 

A  married  woman,  forty-six  years  of  age,  has  just  been  brought  to  the 
hospital.  From  her  daughter  we  learn  the  following  history :  The  patient 
has  been  married  for  twenty-six  years ;  has  never  been  very  strong,  but 
always  comparatively  well.  She  is  the  mother  of  four  healthy  children.  For 
many  years  she  has  felt  a  weakness  in  the  region  of  the  left  groin  and  since 
twelve  years  old  has  known  of  the  presence  of  a  femoral  hernia,  which, 
however,  has  given  rise  to  but  little  distress  except  when  she  has  worked 
beyond  her  strength.  Occasionally  the  hernia  has  been  painful  and  the 
patient  has  experienced  difficulty  in  reducing  it,  but  this  has  never  been 
serious  in  character  and  she  has  always  succeeded  in  obtaining  relief  by 
lying  down  and  applying  hot  cloths  to  the  part  for  an  hour  or  two. 


45°  GENERAL    SURGERY    OF    THE    ABDOMEN 

Three  days  ago  the  patient  suddenly  became  severely  nauseated  and  had 
great  pain  in  the  abdomen.  She  attributed  this  to  something  eaten  and 
imagined  that  it  would  soon  improve.  She  consequently  made  use  of  home 
remedies  and  did  not  send  for  her  physician  until  about  sixteen  hours  ago. 
When  he  arrived  he  found  the  patient  very  ill.  She  still  continued  to  vomit, 
there  had  been  complete  obstruction  to  the  passage  of  gas  and  feces,  the 
abdomen  was  moderately  distended  with  gas  and  the  abdominal  walls  were 
tense.  In  the  region  of  the  left  femoral  ring  there  was  a  hard  mass  the 
size  of  a  hen's  egg.  The  pulse  was  a  little  over  100  and  the  temperature 
101°  F. 

The  physician  made  a  diagnosis  of  strangulated  femoral  hernia,  but  as 
the  patient  did  not  suffer  from  severe  pain  in  the  vicinity  of  the  hernia  he 
did  not  lay  very  great  weight  upon  this  part  of  the  diagnosis.  He  elevated 
the  foot  of  the  bed  in  order  to  make  use  of  gravitation  for  the  purpose  of 
reducing  the  hernia,  gave  a  hypodermic  injection  of  morphia  to  relax  the 
muscles,  directed  the  patient  to  remain  in  the  position  assumed  and  continue 
the  application  of  hot  fomentations.  He  also  forbade  the  giving  of  any  kind 
of  food  by  mouth. 

The  physician  then  left  the  patient  and  returned  after  six  hours,  only 
to  find  her  very  much  worse  in  every  respect.  He  then  advised  an  immediate 
operation,  but  the  husband  could  not  be  found  for  seven  hours  more,  and  by 
the  time  the  latter  was  convinced  of  the  necessity  of  an  operation  the  patient 
was  in  the  present  extreme  condition.  Her  face  is  pale,  lips  blue,  respiration 
very  shallow,  pulse  imperceptible,  and  she  is  without  doubt  in  a  dying  con- 
dition. The  pupils  are  becoming  more  and  more  dilated,  indicating  that 
death  will  occur  within  a  few  moments. 

Such  a  case  is  unusually  instructive  because  the  conditions  present  are 
*o  frequently  encountered  in  practice. 

Prognosis. 

In  the  discussion  of  hernia  operated  for  the  radical  cure,  when  not 
strangulated,  the  fact  was  pointed  out  that  the  operation  is  almost  absolutely 
safe,  the  death  of  a  case  depending  upon  an  accident.  The  same  is  true  in 
operation  for  the  relief  of  strangulated  hernia  at  the  beginning  of  the  attack, 
because  the  only  additional  element,  the  strangulation,  may  be  relieved  with- 
out difficulty  and  without  danger  to  the  patient  so  long  as  there  has  been  no 
injury  to  the  strangulated  intestine.  Consequently  every  death  following  a 
strangulated  hernia — barring  the  accidents  which  may  occur  in  connection 
with  any  operation- — is  due  to  the  fact  that  a  physician  has  not  been  called 
at  the  beginning  of  the  attack,  or  his  advice  to  obtain  immediate  relief  has 
not  been  accepted,  or  the  physician  himself  has  wasted  valuable  time. 

Prompt  Operative  Measures  Necessary. 

There  can  be  no  doubt  but  that  all  temporizing  in  the  treatment  of 
strangulated  hernia  should  IDC  strongly  condemned,  because  cases  in  which 
relief  is  obtained  in  this  manner  could  all  be  relieved  by  manipulation  of  the 
hernia  under  an  anesthetic,  and  those  that  arc  not  relieved  would  recover 
were  they  operated  early.  Every  year  thousands  of  patients  lose  their  lives 
unnecessarily  from  strangulated  hernia  because  time  is  wasted  eifher  on 
account  of  their  own  ignorance  or  stubbornness,  or  because  of  carelessness 
in  examination  by  the  physician  called  or  his  lack  of  decision  in  obtaining 
relief  at  once.  Moreover,  it  should  be  remembered  that  any  practitioner 
who  has  sufficient  intelligence  and  training  to  have  clean  hands  and  instru- 


GENERAL    SURGERY    OF    THE    ABDOMEN  451 

ments,  and  a  fair  knowledge' of  what  to  do,  will  save  a  larger  proportion  of 
cases  suffering  from  strangulated  hernia  by  operating  at  the  beginning  of 
the  attack  than  will  a  surgeon  of  the  very  greatest  skill  and  training  after 
the  tissues  involved  have  become  gangrenous. 

At  this  point  we  wish  to  make  a  suggestion  which  seems  to  be  of  great 
practical  importance  so  long  as  patients  and  their  friends  are  justly  afraid 
of  surgical  operations  for  the  relief  of  strangulated  hernia  because  many  of 
their  friends  who  have  submitted  to  this  operation  have  not  recovered.  It 
is  difficult  for  the  layman  to  understand  that  his  friend  died,  after  an  opera- 
tion for  the  relief  of  strangulated  hernia,  because  the  operation  was  per- 
formed when  he  was  already  in  a  hopeless  condition  ;  for  this  fact  should 
have  prevented  the  operation  which  was  at  least  useless,  as  was  shown  by 
the  result.  It  is  difficult  for  him  to  understand  why  his  own  chance  of 
recovery  should  be  better  than  his  friend's,  inasmuch  as  his  friend  was  urged 
to  submit  to  an  operation  with  the  same  arguments  that  are  being  employed 
in  his  case.  In  other  words,  the  large  number  of  deaths  following  operations 
for  strangulated  hernia,  where  the  operation  had  been  postponed  until  the 
patient  was  in  a  hopeless  state,  prevents  the  operation  in  the  case  undei 
immediate  consideration  until  it,  likewise,  is  too  late  to  be  of  value. 

This  prejudice  can  usually  be  overcome  in  the  following  manner:  De- 
scribe to  the  patient  the  condition  which  is  present ;  tell  him  that  a  loop  of 
intestine  is  caught  in  a  ring  and  constricted  as  tightly  as  his  finger  would  be 
were  a  string  tied  about  it  sufficiently  firm  to  prevent  all  circulation  of  blood. 
He  will  understand  that  this  must  soon  be  followed  by  death  of  the  tissues, 
and  that  then  the  contents  of  the  intestines  will  leak'into  the  abdominal  cavity 
and  that  this  will  be  followed  very  speedily  by  his  death.  Tell  him  that  you 
will  make  every  effort  to  reduce  the  strangulation  by  manipulating  the 
tissues,  in  order  to  induce  the  intestine  to  slip  back  through  the  ring. 

Taxis. 

Place  the  patient  on  a  couch  or  a  board,  or  if  this  cannot  be  obtained 
take  a  door  out  of  its  frame  and  lay  the  patient  on  it ;  then  elevate  the  lower 
end  of  this  so  that  it  will  be  at  an  angle  of  about  40°  with  the  floor.  Have 
him  draw  up  his  knees  and  then  manipulate  the  protruding  portion  gently, 
so  as  not  to  cause  any  injury  to  the  intestine,  remembering  that  the  longer 
the  strangulation  has  existed",  the  more  gentle  must  be  the  manipulations. 

It  is  well  to  permit  the  patient  to  manipulate  the  hernia  himself  while 
he  is  in  this  position,  because  he  is  frequently  more  experienced,  and  conse- 
quently may  be  more  successful  than  the  physician.  If  reduction  is  accom- 
plished, it  is  well,  if  not,  it  is  best  to'  explain  to  the  patient  that  by  relaxing 
the  muscles,  by  the  use  of  an  anesthetic,  you  may  still  be  successful,  but  if 
this  fails,  it  will  become  necessary  to  sever  the  circular  band  which  prevents 
the  reduction  of  the  hernia. 

This  will  seem  so  reasonable  to  the  patient  that  in  our  experience,  with 
only  one  exception,  the  patient  has  always  consented  when  the  conditions 
have  been  placed  before  him  in  this  manner.  One  substitutes  the  object, 
namely,  the  reduction  of  the  hernia,  for  the  operation  in  the  mind  of  the 
patient.  This  is  really  important. 

Operative  Preparation. 

It  is  best  to  permit  the  patient  to  continue  in  the  inverted  position  while 
the  necessary  preparations  are  being  made,  which  should  be  very  simple,  as 
described  in  the  section  on  preparation  for  operation.  If  a  colleague  is 


452  GENERAL    SURGERY    OF    THE    ABDOMEN 

available  he  should  be  called  in  the  meantime,  if  not,  this  should  not  interfere 
with  the  plan  of  action,  because  time  is  the  element  of  greatest  importance 
in  these  cases. 

If  the  patient  is  in  a  hospital  it  is  wise  always  to  anesthetize  the  pharynx 
by  spraying  it  with  a  four  per  cent  solution  of  cocaine  in  water,  then  insert 
a  stomach  tube  and  carefully  wash  out  the  stomach,  because  these  patients 
frequently  vomit  during  the  operation  and  inspire  the  offensive  material 
which  has  decomposed  in  the  stomach,  a  pneumonia  perhaps  resulting.  In 
a  private  house,  especially  in  the  country,  these  preparations  may  not  be 
possible,  although  it  is  well  always  to  carry  a  stomach  tube.  In  this  case 
the  patient  may  be  protected  by  being  kept  in  an  exaggerated  Trendelenburg 
position  throughout  the  anesthesia,  because  in  this  way  the  vomited  material 
will  escape  from  the  mouth  by  gravitation  before  it  can  be  inspired. 

When  the  patient  has  been  thoroughly  anesthetized  another  attempt 
may  be  made  to  reduce  the  hernia  by  manipulation,  and  if  this  fails,  herni- 
otomy  should  be  performed  at  once.  During  these  manipulations  it  is  again 
necessary  to  bear  in  mind  that  if  the  strangulation  has  lasted  only  a  few 
hours  a  considerable  amount  of  force  may  be  exerted  with  safety,  while  it 
is  not  wise  to  use  any  force  if  the  strangulation  has  existed  for  more  than 
twenty-four  hours  for  fear  of  rupturing  the  intestine. 

Symptom  Resume. 

Before  describing  the  operation  we  wish  to  direct  attention  once  more 
to  the  above  history,  which  is  quite  characteristic  in  many  respects.  I.  The 
onset  was  sudden.  2.  There  were  severe  spasmodic  pains  in  the  abdomen. 
3.  The  patient  suffered  from  nausea  and  vomiting  and  consequently  at- 
tributed her  trouble  to  an  error  in  eating.  4.  There  had  been  complete 
obstruction  to  the  passage  of  gas  and  feces.  5.  There  was  a  history  of  the 
presence  of  a  hernia.  6.  A  mass  existed  in  the  groin.  7.  The  patient  felt 
severely  ill  from  the  beginning.  8.  She  went  into  a  hopeless  condition  of 
collapse  very  suddenly. 

The  physical  examination,  when  first  seen  by  the  physician  at  the  begin- 
ning of  her  collapse,  showed  a  patient  with  a  bad  facial  expression,  the 
tongue  was  thickly  coated,  temperature  and  pulse  not  very  high,  but  the 
pulse  bad  in  character,  the  patient  was  restless,  the  abdominal  walls  were 
tense,  the  abdomen  somewhat  distended  with  gas.  The  peristalsis  of  the 
small  intestines  could  be  distinguished  through  the  abdominal  wall  to  some 
extent.  There  was  complete  obstruction  to  the  passage  of  gas  and  feces. 
In  the  inguinal  region  there  was  a  very  tense  swelling  which  could  not  be 
reduced. 

Differential  Diagnosis. 

The  history  of  a  reducible  hernia  which  had  existed  for  a  considerable 
period  of  time,  and  the  presence  of  an  immovable  mass  in  the  inguinal  region 
at  the  point  at  which  the  reducible  hernia  could  be  located  by  the  patient, 
would  in  itself  warrant  a  positive  diagnosis  of  strangulated  hernia  in  the 
presence  of  complete  intestinal  obstruction. 

Without  the  previous  history  of  a  reducible  hernia  the  mass  in  the  groin 
might  be  due  to  a  severe  inflammation  of  the  inguinal  lymph  glands.  We 
have  seen  a  case  of  accute  intestinal  obstruction  due  to  perforative  appendi- 
citis, complicated  with  bubo,  in  which  the  latter  might  have  been  diagnosed 
as  a  strangulated  hernia  had  not  the  attending  physician  treated  the  patient 
previously  for  a  specific  urcthritis.  The  most  common  mistake  in  diagnosis 


GENERAL    SURGERY    OF    THE    ABDOMEN  453 

is  that  of  acute  gastritis,  because  the  physician  is  willing  to  make  a  diagnosis 
from  the  history  alone  without  making  a  physical  examination  of  the  ab- 
domen, the  patient  either  neglecting  to  mention  the  fact  of  having  a  hernia 
or  this  fact  being  passed  over  without  notice.  An  acutely  inflamed  tumor 
in  this  region  may  be  mistaken  for  a  strangulated  hernia. 

In  quite  a  number  of  these  cases  which  have  come  under  our  observa- 
tion the  patient  insisted  that  the  hernia  had  been  irreducible  for  many  years 
and  that  it  could  consequently  not  be  the  cause  of  the  severe  gastric  disturb- 
ances. Moreover,  the  attack  came  on  directly  after  some  indiscretion  in 
eating  and  must  consequently  depend  upon  this  and  not  upon  the  hernia, 
which  had  remained  unchanged.  The  unusual  hardness  of  the  hernia  is 
supposed  to  correspond  to  the  tension  in  the  abdominal  walls,  due  to  the 
intra-abdominal  irritation.  In  this  manner  a  strangulated  hernia  is  mis- 
taken for  a  simple  irreducible  hernia  which  is  caused  by  the  adhesion  of  a 
portion  of  the  omentum  within  the  hernial  sac. 

In  these  cases  the  operation  usually  shows  that  a  loop  of  intestine  has 
slipped  into  the  hernial  sac  alongside  of  the  omentum  and  has  become  strang- 
ulated by  the  sharp  ring  formed  by  the  connective  tissue  in  the  neck  of  the 
hernial  sac. 

A  strangulated  right  inguinal,  or  femoral  hernia,  may  be  mistaken  for 
an  acute  appendicitis.  In  three  instances  we  have  encountered  a  gangrenous 
appendix  in  a  strangulated  hernia,  and  many  such  cases  have  been  reported. 

We  have  encountered  a  preperitoneal  inguinal  hernia,  strangulated  for 
one  week,  containing  20  cm.  of  small  intestine  which  was  strangulated  by 
the  thickened  peritoneal  circular  constricting  band  of  the  internal  abdominal 
ring.  The  intestine  after  passing  through  this  ring  had  passed  between  the 
transversalis  fascia  and  the  peritoneum  instead  of  entering  the  inguinal 
canal.  Here  it  became  gangrenous  and  perforated  without  being  discovered 
until  the  patient  was  brought  into  the  hospital  suffering  from  hopelessly 
advanced  peritonitis. 

A  strangulated  hernia  so  small  as  to  be  overlooked  has  been  mistaken 
for  every  variety  of  mechanical  obstruction  of  the  bowels,  but  if  a  careful 
physical  examination  is  made  this  is  not  likely  to  occur. 

In  almost  every  case  in  which  an  error  in  diagnosis  is  made  in  strangu- 
lated hernia  this  is  due  to  the  fact  that  the  physical  examination  has  not 
been  sufficiently  careful. 

Etiology. 

The  strangulation  is  usually  due  to  the  fact  that  a  small  loop  of  intestine 
has  been  forced  out  into  the  hernial  sac,  which  existed  previously,  by  some 
unusual  exertion,  and  that  the  connective  tissue  forming  the  neck  of  the  sac 
has  constricted  the  intestine  at  the  point  at  which  it  issued  from  the  abdom- 
inal cavity,  and,  interfering  with  the  return  circulation  the  portion  of  the 
intestine  contained  in  the  sac  becomes  congested  and  edematous.  The  drain- 
age from  the  lumen  of  the  intestine  is  obstructed  at  the  same  time,  which 
favors  the  multiplication  of  micro-organisms  contained  in  the  intestinal 
contents.  With  the  increasing  edema  the  circulation  is  presently  shut  off 
entirely  and  the  loop  of  intestine  becomes  gangrenous  and  perishes,  becoming 
an  excellent  nourishing  medium  for  the  micro-organisms  in  its  lumen. 

In  the  meantime  the  complete  intestinal  obstruction  has  injured  the 
portion  of  intestine  above  the  constricting  ring,  because  there  is  a  certain 
amount  of  tension  upon  the  mesenteric  vessels  interfering  with  the  nutrition. 


454  GENERAL    SURGERY    OF    THE    ABDOMEN 

The  pressure  within  the  lumen  of  the  intestines  is  greatly  increased  by  the 
accumulation  of  gas  within  the  bowel,  due  to  the  decomposition  of  the  con- 
tents which  cannot  be  expelled.  Too  often  this  pressure  is  increased  to  a 
marked  extent  by  the  administration  of  food  and  cathartics  by  mouth.  Pres- 
ently the  distension  of  these  intestines  will  be  sufficient  to  permit  transmis- 
sion of  micro-organisms  contained  in  their  lumen  resulting  in  a  direct  infec- 
tion of  the  peritoneal  cavity.  In  the  meantime  again  the  infection  from  the 
gangrenous  intestine  within  the  hernial  sac  may  result  in  a  thrombosis  of  the 
mesenteric  vessels  in  the  intestine  in  the  peritoneal  cavity,  causing  an  exten- 
sion of  the  gangrene. 

Treatment. 

From  the  moment  a  patient  with  strangulated  hernia  comes  under  care 
we  must  absolutely  prohibit  the  giving  of  food  and  cathartics  by  mouth, 
because  this  can  only  serve  to  increase  the  pressure  within  the  intestine  and 
may  also  serve  to  force  infectious  material  through  the  intestinal  wall. 

If  the  patient  comes  under  care  within  the  first  twenty-four  hours  it  is 
usually  safe  to  make  quite  a  prolonged  effort  to  reduce  the  hernia  by  means 
of  manipulations,  the  patient  lying  upon  his  back  with  the  lower  end  of  the 
table  or  couch  elevated  to  an  angle  of  about  40°,  with  the  knees  drawn  up 
in  case  of  femoral  or  inguinal  hernia,  or  with  the  patient  lying  flat  on  his 
back  in  case  of  umbilical  or  ventral  hernia.  But  even  in  theses  cases  which 
come  under  care  early,  we  must  be  careful  not  to  injure  the  intestine  by 
using  too  much  force.  If  the  strangulation  has  existed  much  longer,  still 
greater  caution,  as  before  mentioned,  must  be  exercised.  This  is  especially 
true  of  very  small  hernise  in  which  the  intestine  is  often  hopelessly  destroyed 
even  after  thirty-six  hours,  in  which  case  its  return  to  the  abdominal  cavity 
would  almost  inevitably  result  in  a  diffuse  peritonitis  and  death  of  the 
patient. 

Failing  in  the  reduction,  an  immediate  operation  is  of  course  indicated, 
and  this  can  usually  be  done  directly  after  the  attempt  at  reduction  under 
anesthesia  has  been  made,  without  permitting  the  patient  again  to  gain  con- 
sciousness. 

If  possible,  it  is  always  best  in  these  patients  to  perform  gastric  lavage 
as  described  above.  Aside  from  this  nothing  need  be  done  beyond  carefully 
scrubbing,  shaving  and  disinfecting  the  field  of  operation  and  covering  the 
remaining  portions  of  the  body  with  sterilized  towels. 

Operative  Technique. 

We  will  here  speak  of  the  three  common  forms  of  strangulated  hernia, 
femoral,  inguinal  and  umbilical,  together,  because  the  same  principles  apply 
to  all  alike. 

An  incision  is  made  over  the  center  of  the  swelling,  the  successive  layers 
of  tissue  being  elevated  between  two  pairs  of  dissecting  forceps  in  order  to 
facilitate  the  work  by  protecting  the  underlying  tissues.  If  the  hernia  has 
existed  a  considerable  period  of  time  the  discolored  intestine  will  shine 
through  the  hernial  sac,  which  may  be  smooth  and  shining,  or  it  may  be 
roughened  and  adherent  to  the  overlying  tissues.  This  condition  is  especially- 
likely  to  be  present  if  the  hernia  has  existed  for  a  long  time,  and  if  a  tightly- 
fitting  truss  has  been  worn. 

Precautions. 

If  the  layers  are  picked  up  with  two  pairs  of  forceps  and  the  incision 


GENERAL  SURGERY  OF  THE  ABDOMEN  455 

made  only  through  tissue  thus  elevated  there  is  no  danger  of  wounding  the 
intestine  within  the  hernial  sac.»  Occasionally  one  encounters  a  thick  layer 
of  pre-peritoneal  fat  on  the  outer  surface  of  the  sac  which  looks  so  much 
like  omentum  that  it  is  quite  confusing.  It  is  well  to  watch  for  the  hernial 
fluid  which  can  always  be  found  in  the  sac  in  strangulated  hernia.  Fre- 
quently there  is  a  sufficient  quantity  to  protect  the  contents  of  the  sac  from 
injury  in  making  the  incision,  but  quite  as  often  the  quantity  is  very  slight; 
still  we  believe  it  is  always  sufficient  to  indicate  the  fact  that  the  sac  has  been 
opened. 

There  is,  however,  one  source  of  error  which  has  been  observed  in 
practice.  Occasionally  the  bladder  is  drawn  into  the  hernial  sac  and  this 
has  been  opened  and  the  urine  which  escaped  has  been  mistaken  for  hernial 
fluid.  In  case  of  doubt  in  this  direction  it  is  well  to  introduce  a  steel  sound 
into  jhe  bladder  and  examine  this  organ  in  the  direction  of  the  hernia.  In 
case  the  accident  has  happened  it  is  best  to  suture  the  wound  in  the  blad- 
der at  once  with  a  double  row  of  Lembert  sutures  of  catgut.  It  is  neces- 
sary to  observe  three  precautions  in  suturing  such  a  wound  in  the  blad- 
der: i.  The  stitches  must  be  applied  with  great  regularity  in  order  to 
make  the  closure  impermeable  to  water.  2.  The  stitches  should  not  protrude 
into  the  cavity  of  the  bladder,  in  order  to  prevent  formation  of  stone.  3. 
They  should  be  tied  sufficiently  loose  to  prevent  pressure  necrosis  at  any 
point. 

After  the  hernial  sac  has  been  opened  and  the  hernial  fluid  carefully 
sponged  away,  the  intestine  should  be  inspected.  If  this  is  covered  by  an 
uninjured,  smooth,  shining  peritoneum  it  is  likely  that  it  will  revive  even 
though  it  may  be  quite  black.  It  is  not  wise  to  attempt  its  reduction  with- 
out enlarging  the  constricting  ring  at  the  neck  of  the  hernial  sac  because 
the  strangulated  loop  of  intestine  has  already  suffered  so  severely  that  it 
is  injudicious  to  injure  it  further  by  unnecessary  manipulations. 

Cutting  the  Constricting  Ring. 

Many  methods  of  cutting  the  constricting  ring  have  been  advised,  but 
unless  the  operator  has  through  experience  acquired  especial  skill  in  the 
use  of  one  of  these  methods  we  would  advise  him  to  make  the  incision 
through  all  the  tissues  sufficiently  free  to  expose  the  edge  of  the  con- 
stricting ring  and  then  to  introduce  preferably  a  Kocher  director  between 
the  intestine  and  the  ring  and  then  a  scalpel  or  the  blade  of  scissors  be- 
tween this  and  the  ring,  making  an  incision  transversely  across  the  con- 
stricting tissues.  The  strangulation  is  not  usually  caused  by  the  tissues 
of  the  abdominal  wall,  but  by  a  hard,  inelastic,  fibrous  ring  developed 
from  the  tissues  composing  the  neck  of  the  hernial  sac. 

In  femoral  hernia  it  is  well  to  cut  inward  in  order  to  cut  away  from 
the  femoral  vein.  In  inguinal  hernia  it  is  well  to  cut  in  the  direction  of 
the  inguinal  canal,  first  splitting  the  fibers  of  the  fascia  of  the  external 
oblique  abdominal  muscle,  as  described  in  the  operation  for  radical  cure 
of  inguinal  hernia.  If  it  becomes  necessary  to  cut  the  constricting  band 
without  having  it  exposed  to  sight,  it  is  well  to  insert  the  finger  into  the 
canal  in  order  to  determine  whether  the  epigastric  artery  is  in  the  normal 
position.  If  it  is  it  can  be  easily  avoided  ;  if  it  is  not,  it  will  be  best  to 
enlarge  the  external  wound  until  the  constricting  portion  is  in  view,  when 
it  can  be  cut  safely  over  a  director  or  over  the  finger  which  has  been  in- 
serted between  the  intestine  and  the  constricting  ring.  It  is  now  pos- 


456  GENERAL    SURGERY    OF    THE    ABDOMEN 

sible  to  draw  out  a  further  portion  of  the  intestine  for  inspection.  If 
only  one  portion  has  been  hopelessly  destroyed  by  the  pressure,  this  will 
be  found  just  at  the  point  where  the  intestine  was  grasped  by  the  con- 
stricting ring.  Frequently  the  dark  color  of  the  entire  loop  found  in  the 
hernial  sac  will  begin  to  disappear  after  the  ring  has  been  cut  and  the 
circulation  in  that  portion  of  the  intestine  becomes  re-established. 
Determining  the  Vitality  of  the  Strangulated  Gut. 

Covering  this  portion  with  pads  moistened  with  warm,  normal  salt 
solution  for  a  minute  or  more  the  intestine  appears  more  and  more  normal 
and  when  irritated  by  touching  it  the  muscles  respond  by  contracting.  In 
such  case  it  is  safe  to  return  the  intestine  into  the  abdominal  cavity  and 
so  complete  the  operation  as  described  under  radical  cure. 

Even  if  there  is  no  muscular  contraction,  but  a  satisfactory  return 
of  the  circulation,  it  is  safe  to  return  the  gut,  provided  the  peritoneal  cov- 
ering is  smooth  and  shining.  If,  however,  there  are  areas  of  tissue  upon 
the  peritoneal  surface  which  are  roughened,  or  if  portions  show  by  their 
thinness  that  some  of  the  deeper  layers  of  the  intestinal  wall  are  actually 
necrotic,  it  becames  necessary  to  remove  the  gangrenous  portion  and  to 
unite  the  two  portions  of  intestine  thus  severed. 

The  upper  branch  of  the  intestine  is  always  the  one  which  has  suf- 
fered most  because  the  peristaltic  pressure  has   forced  intestinal  contents 
down  to  the  point  of  obstruction,  consequently  this  portion  of  intestine  is 
often  greatly  distended  with  gas  and  feces. 
Resection  of  Gangrenous  Portion. 

Before  cutting  away  the  gangrenous  portion  of  intestine  it  is  neces- 
sary to  provide  against  infection  of  the  peritoneal  cavity  from  its  con- 
tents by  carefully  placing  warm,  moist  pads  of  gauze  about  the  loop. 
Two  pairs  of  long-jawed  compression  forceps  are  applied  half  an  inch 
apart,  and  two  or  three  inches  from  the  gangrenous  intestine,  upon  the 
lower  segment,  which  is  ordinarily  nearly  normal,  so  as  to  close  the 
lumen  of  the  intestine  completely,  the  points  of  the  forceps  reaching  about 
half  an  inch  beyond  the  mesenteric  attachment  of  the  intestine.  An  in- 
cision is  made  down  to  the  mesentery  between  these  two  forceps,  then 
the  mesentery  of  the  gangrenous  portion  of  the  intestine  is  transfixed  and 
ligated  with  catgut.  It  is  best  to  do  this  in  several  sections  in  order  to 
prevent  slipping  of  the  stump. 

The  intestine  is  cut  loose  from  its  mesenteric  attachment  and  if  great- 
ly distended  above  the  gangrenous  portion  it  is  well  to  have  the  patient 
rolled  over  to  the  side  of  the  operation,  and  after  carefully  applying  moist 
gauze  pads  about  the  wound  to  place  the  end  of  the  intestine  which  has 
been  cut  loose  from  its  mesentery  into  a  basin,  to  grasp  the  cut  edge  at 
different  points  with  hemostatic  forceps  and  then  to  remove  the  long- 
jawed  forceps  closing  the  end  of  the  intestine.  In  this  manner  the 
loosened  intestine  will  act  as  a  tube  through  which  the  contents  of  the 
upper  part  may  safely  be  emptied. 

In  order  to  obtain  a  safe  point  to  unite  the  lower  with  the  upper  seg- 
ment of  the  intestine  it  is  necessary  to  sacrifice,  in  most  cases,  quite  a 
long  piece  of  the  upper  segment.  It  is  a  better  plan  to  close  both  cut  ends 
of  the  intestine  and  make  an  anastomosis  between  the  lower  segment  near 
its  end  and  the  upper  segment  far  enough  from  its  end  to  be  certain  that 
the  intestinal  walls  are  quite  normal.  In  this  way  quite  as  good  a  union 


GENERAL    SURGERY    OF    THE    ABDOMEN  457 

can  be  obtained  as  by  resecting  a  large  portion  of  the  upper  segment,  and 
much  time  is  saved  in  the  operation,  as  well  as  much  shock,  because  the 
amount  of  traumatism  is  very  greatly  decreased  in  this  manner. 

The  portion  of  the  upper  segment  of  the  intestine  below  the  point  of 
anastomosis  remains  perfectly  harmless. 

The  methods  of  closing  the  ends  of  the  severed  intestine  and  making 
the  anastomosis  are  fully  described  in  the  section  on  intestinal  surgery. 

Removal  of  Bowel  Contents. 

In  other  cases  in  which  it  is  not  necessary  to  make  a  resection  of  the 
bowel,  the  distended  intestine  should  be  emptied  after  the  method  of  Marks. 
This  consists  in  placing  a  purse-string  stitch  in  the  wall  of  the  distended 
intestine  making  a  circle  about  I  cm.  in  diameter,  the  ends  of  the  stitch 
remaining  loose.  An  opening  is  now  made  in  the  center  of  the  purse- 
string  area  and  a  glass  tube  about  2  cm.  in  diameter  and  about  30  cm. 
long  is  inserted  into  the  intestine  and  the  purse-string  is  now  tied  to  pre- 
vent leakage  around  the  tube.  A  large  rubber  tube  is  slipped  onto  the 
free  end  of  the  tube  and  its  free  end  placed  in  a  basin.  The  intestine  is 
now  gradually  threaded  onto  this  glass  tube  and  as  this  is  done  the  in- 
testinal contents  are  all  forced  out  through  the  glass  tube.  A  loop  of  in- 
testine at  about  the  center  of  the  distended  intestines  should  be  chosen  as 
a  point  to  insert  the  tube.  The  glass  tube  is  first  directed  toward  the  upper 
end  of  the  intestinal  canal  and  this  half  emptied.  The  tube  is  then  with- 
drawn until  it  can  be  directed  down  the  lower  half  of  the  intestine  which 
is  now  threaded  on  the  tube,  emptying  this  portion  of  the  bowel.  The 
tube  is  now  removed  and  the  opening  in  the  intestine  closed  by  tying  the 
purse-string  stitch  and  placing  a  Lembert  stitch  over  it.  This  process  re- 
moves a  large  amount  of  septic  material  from  the  alimentary  canal  and 
leaves  the  intestine  in  a  collapsed  condition. 

After-Treatment. 

After  operation  for  strangulated  hernia  no  food  should  be  given  by 
mouth  for  several  days,  and  then  only  predigested  substance  and  later 
broths,  soups  and  milk.  The  patient  may  be  nourished  by  enemata  con- 
sisting of  one  ounce  of  some  predigested  food  dissolved  in  three  ounces 
of  normal  salt  solution  given  every  four  hours.  Cathartics  should  not  be 
used  until  at  least  a  week  after  the  operation,  and  then  only  mild  salines 
in  small,  often  repeated  doses.  Small  sips  of  very  hot  water  may  usually 
be  given  from  the  first. 

The  treatment  of  the  wound  must  be  left  to  the  judgment  of  the  op- 
erator. If  it  seems  wise  to  close  the  wound  this  is  done  in  the  manner 
described  in  operations  for  radical  cure,  except  in  femoral  hernia.  In 
femoral  hernia  the  defect  made  in  the  ring  by  cutting  the  constriction 
must  be  repaired  in  order  to  prevent  the  recurrence  of  the  hernia.  This 
can  be  accomplished  very  readily  with  a  few  interrupted,  chromicized  cat- 
gut stitches.  In  all  other  respects  the  same  methods  may  be  followed  as 
in  operation  for  radical  cure. 

If  in  any  given  case  it  seems  unwise  to  close  the  hernial  opening  at 
once  it  is  well  to  insert  a  glass  or  rubber  drainage  tube,  covered  with  iodo- 
form  gauze,  through  the  hernial  opening  down  to  the  injured  intestine. 
It  has  been  our  practice  to  withdraw  this  tube  on  the  second  or  third  day, 
and  after  that  to  withdraw  the  gauze  gradually,  by  pulling  upon  it  as  much 
as  seems  wise  each  day.  If  the  wound  suppurates,  it  is  to  be  treated  like 


GENERAL    SURGERY    OF    THE    ABDOMEN 

an  infected  wound  elsewhere.  If  it  remains  aseptic  it  may  be  closed  by 
means  of  secondary  sutures  a  week  after  the  original  operation. 

This  operation  must  frequently  be  performed  in  old  and  feeble  pa- 
tients, and  these  do  not  bear  confinement  in  bed  well.  It  is  consequently 
wise  to  encourage  their  moving  about  in  bed  and  sitting  up  early. 

If  a  fecal  fistula  occurs  it  is  well  to  continue  the  feeding  by  enema 
for  two  or  three  weeks,  which  will  usually  suffice  for  a  spontaneous  cure. 
If  the  fistula  persists  it  may  become  necessary  to  make  an  abdominal  sec- 
tion for  its  relief,  the  technique  of  which  will  be  found  under  intestinal 
surgery. 

If  the  patient  seems  too  weak  to  bear  the  operation  of  anastomosis 
of  the  two  portions  of  the  intestine,  or  if  the  operator  who  performs  the 
operation  does  not  feel  competent  to  conduct  this  part  of  the  work,  tem- 
porary relief  may  be  given  by  drawing  out  the  intestine  for  a  distance  of 
two  or  three  inches  through  the  enlarged  hernial  opening,  placing  strands 
of  gauze  between  the  intestine  and  the  edges  of  the  opening,  ligating  the 
mesentery  of  the  gangrenous  portion,  cutting  away  the  latter  and  leaving 
the  ends  of  the  intestine  open  for  drainage  and  leavingr  the  construction 
of  an  anastomosis  for  future  consideration. 

Important  Points. 

The  points  which  should  be  impressed  especially  in  connection  with 
this  subject  are:  i.  The  necessity  of  always  making  a  physical  examina- 
tion in  cases  suffering  from  intra-abdominal  pain,  nausea  or  vomiting, 
and  always  to  examine  for  hernia  in  these  cases  because  this  will  enable 
the  physician  to  make  an  early  diagnosis.  2.  The  necessity  of  relieving 
the  strangulation  at  once.  3.  The  fact  that  these  cases  are  more  likely 
to  recover  if  relieved  of  the  strangulation  early  by  a  clean  physician  or 
surgeon  with  little  or  no  experience,  than  by  a  surgeon  with  the  greatest 
possible  skill  if  operated  late. 

DIAPHRAGMATIC  HERNIA. 

Diaphragmatic  hernias  are  very  rare  and  when  they  do  exist  are  sel- 
dom diagnosed  before  the  abdomen  is  opened.  The  majority  of  cases 
that  have  been  reported  have  been  found  post-mortem. 

Diaphragmatic  hernia  may  be  congenital  or  acquired.  The  congenital 
variety  is  rarely  amenable  to  surgical  treatment,  because  so  great  a  por- 
tion of  the  diaphragm  is  absent  that  it  is  impossible  to  close  the  large 
opening. 

The  acquired  variety  may  frequently  be  benefited  by  operation.  These 
hernise  may  follow  stab  wounds,  gunshot  wounds  and  crushing  injuries, 
or  they  may  develop  through  one  of  the  normal  openings  in  the  diaphragm 
from  any  cause  producing  an  increased  intra-abdominal  pressure.  The 
most  frequent  site  for  the  hernia  to  take  place  is  through  the  opening  of 
the  esophagus. 

The  symptoms  of  diaphragmatic  hernia  are  most  commonly  those  of 
strangulation  of  some  of  the  abdominal  viscera,  but  the  real  cause  of  the 
strangulation  is  rarely  diagnosed  until  the  abdomen  is  opened. 

There  can  be  no  definite  operation  planned  for  the  relief  of  these 
cases.  There  is  a  difference  of  opinion  among  surgeons  as  to  the  method 


GENERAL    SURGERY    OF    THE    ABDOMEN  459 

of  approaching  such  a  hernia.  Some  advise  attacking  it  through  the 
pleural  cavity,  while  others  prefer  the  abdominal  route. 

In  many  of  these  cases  the  stomach  and  nearly  all  of  the  intestines 
are  found  in  the  hernial  cavity. 

The  very  large  hernias  are  hopeless  as  far  as.  closure  of  the  hernial 
opening  is  concerned.  In  two  cases  Mayo  was  able  to  close  the  hernial 
opening  by  suturing  the  wall  of  the  stomach  to  the  edges  of  opening  in 
the  diaphragm  and  to  the  abdominal  wall  and  parietal  peritoneum  in  sev- 
eral places.  Both  patients  made  a  good  recovery. 

SPLENECTOMY. 

This  operation  is  "indicated,  aside  from  cases  in  which  the  spleen  is  the 
seat  of  a  severe  traumatism,  only  in  patients  in  whom  the  size  of  the  spleen 
is  in  itself  a  burden,  and  in  whom  medical  treatment  diligently  applied  has 
failed  to  relieve.  It  is  contra-indicated  in  cases  of  splenic  leukemia  having 
a  leucocytosis  of  more  than  50,000  because  these  patients  regularly  die  of 
shock  or  hemorrhage,  while  they  frequently  live  in  relative  comfort  for  a 
considerable  period  of  time  if  not  operated. 

History. 

The  patient  exampled  is  a  school  boy  twelve  years  of  age.  He  has  lived 
in  this  city  since  birth,  has  never  been  strong,  but  until  two  years  ago  he 
had  never  been  sick  in  bed.  At  that  time  he  began  to  feel  weak  and  languid 
and  to  lose  in  flesh  and  look  badly.  At  the  same  time  he  noticed  a  small 
swelling  in  the  left  hypochondriac  region.  All  of  these  conditions  have 
slowly  but  constantly  become  worse  notwithstanding  constant  treatment.  He 
came  under  our  observation  two  months  ago,  since  which  time  he  has  been 
treated  continuously.  First  he  received  tonics  containing  arsenic,  then  phos- 
phorus ;  then  he  was  given  two  grains  of  quinine  in  solution  every  two 
hours  night  and  day  for  thirty  doses,  which  was  repeated  after  an  interval 
of  six  days,  in  order  to  keep  fresh  quinine  in  his  circulation  constantly  to 
counteract  any  malarial  infection  which  might  have  escaped  detection ;  the 
examination  of  the  blood  having  failed  to  show  the  presence  of  the  plas- 
modium  of  malaria.  All  of  these  forms  of  treatment  had  a  negative  result. 
The  same  was  true  of  the  use  of  iodide  of  potassium,  which  had  been  given 
experimentally  some  time  before. 

Present  Condition. 

Somewhat  emaciated,  anemic,  tongue  coated,  appetite  fair,  bowels 
slightly  constipated,  pulse  70,  lungs  and  kidneys  normal.  Examination  of 
blood  shows  a  count  of  3.500,000  red  and  6,000  white  corpuscles.  The  lymph 
gland?  are  nowhere  enlarged.  The  abdomen  is  considerably  more  prominent 
on  the  left  than  on  the  right  side.  Palpation  shows  a  tumor  extending  from 
a  point  one  inch  below  the  left  costal  arch  to  an  inch  above  the  anterior 
superior  spine  and  a  little  beyond  the  middle  line  to  the  right.  Pressing 
forward  from  behind  the  tumor  moves  toward  the  right  side  of  the  abdomen. 
Several  deep  notches  can  be  felt  in  the  relatively  sharp  edge  on  the  right 
side.  The  tumor  is  not  freely  movable.  It  i?  slightly  displaced  by  respiration. 

Diagnosis. 

The  most  characteristic  feature  in  this  case  is  the  form  of  the  tumor, 
being  oblong  from  above  downward  with  a  sharp  border  on  its  right  side 
and  distinct  notches  in  this  border. 


460  GENERAL    SURGERY    OF    THE    ABDOMEN 

All  of  these  characteristics  would  not  be  present  in  a  tumor  of  the 
kidney  or  the  descending  colon,  the  only  organs  in  which  tumors  occasionally 
develop   in   this   vicinity,   hence   an   enlarged    spleen    is   the   only   probable 
diagnosis. 
Indications  for  Treatment. 

Internal  treatment  has  been  patiently  and  carefully  employed  for  two 
years,  and  during  the  past  two  months  under  our  observation.  Had  the 
spleen  been  enlarged  because  of  a  malarial  infection  the  treatment  with 
quinine  and  arsenic  would  have  made  an  impression.  The  diagnosis  of 
malaria  seemed  plausible  because  the  child  has  lived  near  the  north  branch  of 
the  Chicago  river  in  a  vicinity  infested  with  mosquitoes,  which  breed  in 
the  clay  holes  of  an  old  brickyard  containing  stagnant  water  and  refuse. 
It  is  true  that  the  examination  of  the  blood  failed  to  discover  the  plasmodium, 
but  this  might  be  accounted  for  by  the  chronic  condition,  which  makes  it 
much  more  difficult  to  find  the  parasite.  The  tumor  continues  to  increase 
in  size  and  encroaches  upon  the  other  organs. 

Were  the  proportion  of  white  to  red  blood  corpuscles  greatly  increased, 
indicating  the  presence  of  leukemia,  an  operation  would  be  positively  contra- 
indicated,  because  in  that  case  either  primary  or  secondary  hemorrhage  is 
sure  to  occur  and  the  patient  never  survives  the  operation  if  this  condition 
is  at  all  advanced.  It  seems  safe  to  place  a  leucocytosis  of  50,000  as  the 
upper  limit  of  safety  for  the  operation  of  spleenectomy.  Before  operation 
these  patients  should  receive  a  liberal  diet  of  milk  with  the  albumen  of  six 
to  ten  eggs  daily,  the  latter  best  given  in  fruit  juices  in  order  to  increase 
the  palatability. 

The  blood  must,  of  course,  be  examined  repeatedly  for  the  presence 
of  the  plasmodium  malarise,  because  its  presence  would  indicate  the  possi- 
bility of  obtaining  a  reduction  in  the  size  of  the  spleen  by  the  systematic 
use  of  quinine  and  arsenic.  The  former  remedy  should  be  given  in  solution 
in  two-grain  doses  every  two  hours  night  and  day  for  thirty  doses,  then 
one-fiftieth  of  a  grain  of  arsenious  acid  should  be  given  at  intervals  of 
three  hours,  six  times  daily,  for  six  clays,  then  the  course  of  thirty  two- 
grain  doses  of  quinine  should  be  repeated.  This  method  insures  the  pres- 
ence of  fresh  quinine  in  the  body  constantly  and  is  much  more  effective  in 
these  chronic  cases  than  when  given  in  larger  doses  at  longer  intervals ;  in- 
deed, many  cases  in  which  enormous  closes  of  quinine  given  from  two  to 
four  times  a  day  had  no  permanent  effect  after  treatment  for  weeks  or 
months,  have  recovered  after  ten  days'  treatment  by  this  method.  We  have 
had  an  opportunity  of  testing  this  method  in  a  large  number  of  cases  of 
chronic  tropical  malaria  and  have  found  it  absolutely  reliable.  It  is  well  to 
give  these  patients  two  ounces  of  castor  oil  in  the  foam  of  malt  or  beer 
daily  during  this  course  of  treatment  in  order  to  ensure  perfect  absorption  of 
the  remedies. 

Operation. 

The  length  of  incision  will  depend  upon  the  size  of  the  tumor.  It  is 
most  convenient  to  make  it  along  the  outer  border  of  the  left  rectus  abdo- 
minis  muscle,  or  through  the  outer  edge  of  this  muscle.  It  should  be  quite 
long  enough  to  permit  of  all  the  manipulations  without  crowding,  because 
the  safety  of  the  operation  depends  largely  upon  the  absence  of  traumatism. 

It  is  important  to  loosen  the  peritoneal  support  of  the  spleen  before 
the  blood  vessels  are  interfered  with.  First  the  phreno-splenic  ligament  is 


PLATE  LXIII. 

Showing  vessels  of  spleen  clamped  by  long  forceps,  jaws  protected  by  rubber  tubes. 
(Mayo.) 


GENERAL    SURGERY    OF    THE    ABDOMEN  463 

grasped  between  two  pair  of  large  pressure  forceps  and  cut  between.  The 
phrenic  end  is  then  carefully  transfixed  and  ligated,  the  forceps  on  the 
splenic  end  being  left  in  place.  Then  the  peritoneal  support  not  included  in 
this  structure  is  treated  in  the  same  manner. 

If  there  are  any  inflammatory  adhesions  they  are  treated  as  in  all  other 
intra-abdominal  operations.  When  the  spleen  has  been  made  free  slowly 
and  carefully,  without  unnecessary  traumatism,  down  to  the  hilus  to  which 
is  attached  the  gastro-splenic  omentum  containing  the  important  blood  ves- 
sels, this  is  loosened  above  and  below  to  form  a  pedicle,  which  may  be 
grasped  with  a  pair  of  heavy  pressure  forceps,  or  it  may  be  transfixed  with 
a  blunt  aneurysm  needle  and  tied  in  halves  with  cat-gut,  a  second  ligature 
being  applied  around  the  entire  pedicle  at  a  point  one-eighth  or  one-fourth 
of  an  inch  away.  The  pedicle  is  then  cut  beyond  these  ligatures  and  the 
separate  branches  of  the  splenic  artery  and  vein  may  be  tied  once  more 
separately.  If  the  pressure  forceps  are  applied  instead  of  first  ligating  the 
pedicle,  the  pedicle  may  be  cut  a  short  distance  beyond  the  forceps ;  then 
the  vessels  may  be  picked  up  at  their  ends  and  ligated  separately,  and  then 
the  ligature  may  be  thrown  around  the  pedicle  just  above  the  point  at  which 
the  forceps  were  applied.  The  forceps  are  taken  off  while  the  ligature 
is  being  tied,  which  will  permit  the  latter  to  slip  into  the  groove  made  by 
the  former. 

Any  raw  surfaces  which  may  remain  are  covered  with  peritoneum  by 
means  of  cat-gut  sutures. 

In  case  there  are  areas  which  cannot  be  covered,  from  which  there  is 
a  considerable  amount  of  oozing,  they  should  be  tamponed  with  iodoform 
gauze,  which  should  be  permitted  to  protrude  from  the  wound ;  otherwise 
the  wound  is  closed  in  the  usual  manner,  great  care  being  taken  to  have 
each  layer  in  accurate  apposition. 

In  all  cases  in  which  the  leucocytosis  exceeds  20,000  it  is  well  to  make 
a  drainage  opening  through  the  back  and  to  carry  one  or  two  glass  or  rubber 
drainage  tubes  from  the  seat  of  operation  through  this  opening.  These 
may  be  removed  after  two  or  three  days. 

The  after  care  of  these  patients  is  the  same  as  following  other  abdominal 
sections. 

WANDERING  SPLEEN. 

Occasionally  a  spleen  will  become  extremely  movable  so  that  it  may 
be  dislocated  to  all  parts  of  the  abdominal  cavity.  This  may  be  accompanied 
by  a  considerable  amount  of  suffering  in  the  form  of  acute  pain  and  digestive 
disturbances. 

In  these  cases  the  phreno-splenic  ligament  is  drawn  out  so  that  it  no 
longer  serves  as  a  support,  and  the  other  peritoneal  support  is  equally  useless. 
This  pedicle  may  become  twisted  and  may  give  rise  to  severe  pain  or  even 
collapse.  It  may  give  rise  to  a  diagnosis  of  acute  mechanical  obstruction 
of  the  intestines. 
Operation. 

The  incision  described  in  the  previous  operation  is  again  employed, 
then  the  outer  edge  of  the  wound  is  retracted  thoroughly  and  a  pouch  formed 
out  of  the  parietal  peritoneum  and  transversalis  fascia  sufficiently  large  to 
conveniently  hold  the  spleen  which  is  sutured  in  place.  What  is  left  of 
the  phreno-splenic  ligament  is  utilized  in  fastening  the  spleen  in  this  position. 


464  GENERAL    SURGERY    OF    THE   ABDOMEN 

In  performing  this  operation  care  should  be  taken  not  to  do  anything  which 
might  interfere  with  the  blood  vessels  in  the  gastro-splenic  omentum. 

In  case  the  pedicle  has  been  twisted,  or  the  operation  just  described 
does  not  promise  permanent  relief,  it  is  best  to  remove  the  organ  which 
can  be  done  with  the  greatest  ease  in  these  cases  by  simply  ligating  the 
pedicle  and  cutting  it  off  two  cm.  beyond  the  ligature. 

These  patients  do  not  suffer  from  the  loss  of  this  organ. 

The  case  whose  history  was  given  above  has  now  been  under  observa- 
tion for  a  period  of  twelve  years.  He  has  shown  no  ill-effects  from  his 
loss  of  spleen.  Four  years  after  the  operation  he  had  a  severe  pneumonia 
which  took  a  normal  course  and  during  this  attack  examination  of  his  blood 
showed  the  same  conditions  as  in  other  cases  suffering  from  pneumonia  at 
the  same  time  in  the  same  hospital  ward. 

PANCREATITIS. 

Since  the  surgeon  has  come  to  consider  pancreatitis  habitually  with  the 
same  uniform  system  that  he  considers  all  other  important  intra-abdominal 
pathologic  conditions,  our  appreciation  of  its  importance,  as  well  as  our 
knowledge  of  this  condition,  has  acquired  reasonable  dimensions. 

Etiology. 

Undoubtedly,  the  infection  usually  travels  up  the  common  duct  into 
the  gall-bladder  where  there  is  a  possibility  for  the  accumulation  of  a  large 
quantity  of  infected  bile  mixed  with  mucus,  which  on  its  way  down  the 
common  duct  is  easily  diverted  into  the  pancreatic  duct  if  there  is  obstruc- 
tion from  gall-stones  or  edema  below  the  point  at  which  the  duct  of  Wirsung 
empties  into  the  common  duct. 

In  our  cases  the  irritation  of  the  common  duct  has  been  due  quite  as 
often  to  the  passage  of  infected  sandy  bile  as  to  the  presence  of  gall-stones. 

There  is  much  difference  in  the  statistics  of  various  authors  regarding 
the  relative  frequency  with  which  pancreatitis  accompanies  gall-stones.  This 
is  probably  due  to  the  fact  that  the  diagnosis  of  pancreatitis  is  based  on 
the  impression  the  surgeon  obtains  from  palpating  the  gland  during  opera- 
tion, and  one  surgeon  may  consider  the  gland  practically  normal  in  an  indi- 
vidual instance  in  which  the  same  condition  would  impress  another  surgeon 
as  representing  a  certain  degree  of  enlargement. 

Unless  a  surgeon  has  examined  many  cases  in  which  the  abdomen  was 
opened  for  conditions  which  could  have  no  relation  with  the  pancreas,  in 
order  to  become  familiar  with  the  feeling  of  a  normal  pancreas,  it  is  not 
likely  that  his  judgment  in  this  matter  can  be  entirely  satisfactory. 

It  is  therefore  well  to  palpate  the  pancreas  in  cases  of  operation  for 
the  removal  of  uterine  fibroids  or  ovarian  cysts  and  other  similar  conditions. 
This  can  be  done  readily  while  the  surgeon's  hand  is  in  the  upper  portion 
of  the  abdomen  for  the  purpose  of  examining  the  gall-bladder. 

All  surgeons  with  large  experience  in  this  special  direction  seem  to 
agree  that  pancreatitis  patients  almost  invariably  suffer  from  disease  of 
the  gall-bladder  or  ducts,  and  that  gall-stones  in  the  common  duct  are  more 
commonly  accompanied  by  pancreatitis  than  stones  in  the  gall-bladder. 

It  has  been  suggested  by  Williams  and  Bush,  and  apparently  confirmed 
by  careful  experimentation,  that  anatomic  peculiarities  interfering  with  the 
free  drainage  of  pancreatic  juice  through  the  ducts  of  Santorini  or  Wirsung 


GENERAL    SURGERY    OF    THE    ABDOMEN  465 

provide  favorable  conditions  for  the  infection  of  the  pancreas.  It  is  plain 
that  when  the  natural  conditions  for  free  drainage  of  pancreatic  juice  are 
unfavorable,  complete  obstruction,  due  to  the  presence  of  gall-stones  or 
edema,  is  much  more  likely  to  occur. 

The  colon  bacillus  is  the  most  common  cause  of  the  infection,  and  is 
frequently  associated  with  the  streptococcus  and  the  staphylcoccus. 

Pancreatitis,  in  common  with  all  inflammatory  diseases  of  the  gall- 
bladder and  ducts,  frequently  follows  inflammatory  diseases  of  the  gastro- 
intestinal tract. 

After  the  pancreas  has  once  been  infected  a  species  of  vicious  circle  is 
developed  from  the  fact  that  the  swollen  pancreas  obstructs  the  portion  of 
the  common  duct  which  passes  through  the  head  of  this  organ,  which  favors 
the  development  of  septic  micro-organisms  above  this  point  as  well  as  their 
further  backing  up  into  the  pancreas.  It  is  for  this  reason  that  the  free 
draina-ge  due  to  cholecystostomy  has  given  such  uniformly  favorable  results. 

All  these  facts  seem  to  bear  out  the  theory  commonly  accepted  at  the 
present  time  that,  barring  the  rare  occurrence  of  metastatic  infection,  pan- 
creatitis is  due  to  infection  from  the  alimentary  canal,  usually  through  the 
biliary  passages,  or,  according  to  Maugaret,  more  especially  through  the 
lymphatic  system  of  these  passages.  The  acute  violent  cases  of  hemorrhagic 
pancreatitis  are  apparently  due  to  retrograde  injection  of  the  pancreas  with 
infected  bile  and  pancreatic  juice  which,  according  to  Flexner,  must  be  in 
a  relatively  concentrated  form.  In  these  cases  which  take  a  violent  acute 
course  there  is  commonly  a  rapid  destruction  of  the  gland  parenchyma. 
In  the  chronic  forms,  on  the  other  hand,  the  inflammation  results  in  interlob- 
ular  fibrous  tissue  hyperplasia.  The  secreting  cells  of  the  acini  are  more 
readily  destroyed  than  the  islands  of  Langerhans.  This  fact  would  account 
for  the  relative  infrequency  of  glycosuria  in  mild  or  early  cases  of  pancre- 
atitis. 

Diagnosis. 

Until  recently  the  diagnosis  of  pancreatitis  was  made  incidentally  only 
during  the  progress  of  operations  on  the  gall-bladder  or  biliary  tracts  and 
the  stomach.  Since  the  attention  of  surgeons  was  generally  directed  to 
this  condition  by  Mayo  Robson,  Riedel,  Mayo  and  others,  the  diagnosis  has 
frequently  been  made  before,  and  confirmed  during,  the  operation.  From 
this  it  has  become  possible  to  associate  the  condition  of  pancreatitis  with 
a  number  of  more  or  less  typical  diagnostic  signs  observed  before  operation. 

In  1904  Cammidge,  in  connection  with  the  clinical  work  of  Mayo 
Robson,  brought  out  a  most  ingenious  chemical  test  which  promised  to  be 
of  great  value  in  the  diagnosis  of  this  condition. 

The  method  has  been  described  most  clearly  by  Schroeder,  as  follows : 

Forty  c.c.  of  the  urine,  filtered,  acid  reaction,  free  from  albumin  and 
sugar,  are  boiled  with  2  c.c.  of  strong  hydrochloric  acid  for  ten  minutes. 
After  partly  cooling-,  8.0  gm.  of  lead  carbonate  are  gradually  added.  When 
the  reaction  is  complete,  the  mixture  is  chilled,  filtered  and  the  excess  of 
lead  in  solution  removed  by  addition  of  2  gm.  of  sodium  sulphate  bringing 
the  mixture  to  a  boil,  chilling  and  filtering  to  20  c.c.  To  this  filtrate  is  now 
added  a  mixture  of  phenylhydrazin  hydrochlorate  0.80  gm.,  sodium  acetate 
2.0  gm.  and  of  50  per  cent,  glacial  acetic  acid  i  c.c.  and  the  whole  is  boiled 
on  a  sand-bath  for  ten  minutes.  The  solution  is  then  filtered  while  hot  and 
set  aside  to  crystallize.  The  precipitation  of  crystals,  sometimes  only  in 


466  GENERAL    SURGERY    OF    THE    ABDOMEN 

microscopic  quantities,  of  the  characteristic  formation  of  ozazones,  makes  a 
positive  reaction. 

In  1905  we  had  a  large  number  of  tests  made  at  the  Augustana  Hospital 
laboratory  on  patients  who  were  later  operated  on,  so  that  the  findings 
could  be  judged  as  to  their  reliability  by  the  actual  examination  of  the 
pancreas.  These  tests  were  carried  out  by  Dr.  J.  L.  Yates,  then  chief  assist- 
ant, whose  large  experience  as  a  carefully  trained  laboratory  investigator 
fitted  him  particularly  for  this  task.  He  had,  moreover,  assisted  in  the 
diagnosis,  operation  and  after-treatment  of  a  great  number  of  cases  belong- 
ing to  this  special  group,  so  that  he  also  possessed  a  large  experience  as  a 
clinical  surgeon. 

These  tests  were  extremely  fascinating,  but  it  seemed  to  us  that  it  re- 
quired too  much  of  the  personal  element  of  the  observer  to  make  the  method 
useful  except  in  the  hands  of  unusually  skillful  experts. 

The  fact  that  surgeons  like  Robson  and  Moynihan  continue  to  trust 
this  test  is,  however,  sufficiently  important  to  convince  us  that  it  contains 
real  merit. 

Symptoms. 

If  we  add  to  the  well-known  symptoms  of  cholecystitis  an  area  of 
tenderness  from  5  to  10  cm.,  long,  located  to  the  right  of  the  umbilicus 
over  the  middle  of  the  right  rectus  abdominis  muscle,  in  cases  in  which  we 
can  exclude  a  diagnosis  of  duodenal  ulcer,  we  have  the  typical  symptoms 
on  which  to  make  a  diagnosis  of  pancreatitis. 

In  duodenal  ulcers  there  are  two  symptoms  usually  present  which  are 
not  symptoms  of  pancreatitis:  (i)  pain  before  meals  when  the  stomach 
is  empty,  and  (2)  hyperchlorhydria  with  eructations. 

In  pancreatitis  there  is  frequently  referred  pain  to  the  mid-scapular 
or  left  scapular  regions.  In  gastric  ulcer  the  same  pain  is  commonly  present, 
but  with  this  there  is  pain  on  deep  pressure  at  a  point  half-way  between 
the  ensiform  appendix  of  the  sternum  and  the  umbilicus. 

There  are,  of  course,  cases  in  which  two  or  more,  or  all  of  these,  con- 
ditions are  present  in  the  same  patient,  and  other  cases  in  which  it  is  pos- 
sible only  to  determine  the  fact  that  one  or  more  of  these  conditions  are 
present,  while  a  strict  differential  diagnosis  may  not  be  possible.  In  these 
cases,  however,  it  is  quite  possible  to  determine  the  necessity  of  an  explora- 
tory incision,  and,  when  the  indications  for  this  are  not  clear,  then  it  is 
usually  safe  to  keep  the  patient  under  dietetic  treatment  until  further  study 
has  cleared  up  the  diagnosis. 

Solomon  has  pointed  out  the  fact  that  in  the  presence  of  pancreatitis 
von  Noorden's  oatmeal  diet  gives  rise  to  typical  butter  stools  and  that  an 
abnormally  large  amount  of  lecithin  is  excreted.  From  0.4  to<  1.2  gm.  is 
excreted  in  twenty-four  hours  when  these  patients  are  placed  on  an  egg 
diet,  while  normal  individuals  excrete  not  to  exceed  o.i  gm.  under  similar 
feeding. 

According  to  Schlecht,  Mueller's  test  is  quite  reliable.  The  patient  is 
given  a  test  meal  which  is  followed  after  two  hours  by  a  calomel  purge. 
A  few  drops  of  the  stool  are  sterilized  by  heat,  then  placed  on  an  agar  plate 
containing  Loeffer's  serum.  The  plates  are  kept  in  an  oven  at  131  to  141°  F. 
for  twenty-four  hours.  If  trypsin  is  present  the  serum  shows  pronounced 
depressions,  if  absent  the  surface  is  smooth.  Lepine  has  made  most  interest- 
ing but  very  complicated  experiments  which  he  claims  are  valuable  in  the 
diagnosis  of  this  condition. 


GENERAL    SURGERY    OF    THE    ABDOMEN  467 

In  advanced  cases  there  is  usually  marked  emaciation,  frequently  with 
peculiar  circumscribed  areas  of  fat  in  roll-like  masses  on  the  front  and 
sides  of  the  chest  and  abdomen.  There  is  usually  marked  anemia  present, 
often  approaching  chlorosis  with  degeneration  of  the  erythrocytes.  Many 
of  these  patients  suffer  from  obstinate  constipation,  while  others  have  equally 
troublesome  diarrhea. 

Sugar  is  present  in  only  a  small  proportion  of  these  cases. 
Treatment  of  Chronic  Pancreatitis. 

The  treatment  must  consist  primarily  in  relieving  the  irritation  due  to 
the  backing  up  of  infected  bile  by  establishing  free  drainage  which  must 
be  sufficiently  permanent  to  permit  complete  restoration  of  gall-bladder  and 
ducts  as  well  as  the  pancreatic  ducts.  It  is  important  to  keep  the  intestines 
and  stomach  normal  and  free  from  irritation  permanently  by  the  use  of 
proper  diet  and  hygiene  after  these  operations. 

In  case  gall-stones  or  pancreas  stones  are  present,  these  must  be  re- 
moved, whatever  their  location  may  be.  In  rare  cases  in  which  the  common 
duct  is  permanently  obstructed,  cholecystenterostomy  may  be  indicated. 

It  is  probably  best  to  make  the  anastomosis  between  the  gall-bladder 
and  duodenum  where  possible,  and  between  the  gall-bladder  and  jejunum 
through  an  opening  in  the  transverse  mesocolon  where  the  duodenum  cannot 
be  safely  reached.  The  suture  method  should  be  employed  similar  to  the 
one  used  in  posterior  gastro-enterostomy. 

Surgical  Treatment  of  Chronic  Pancreatitis. 

In  chronic  pancreatitis  the  treatment  originally  practised  and  advised 
by  Mayo  Robson,  consisting  in  the  establishment  of  perfect  drainage  through 
a  cholecystostomy  opening,  seems  to  be  still  the  best.  The  edema  of  the 
common  duct  and  the  pressure  and  consequent  obstruction  due  to  the  pres- 
ence of  an  enlarged  pancreas  are  thus  relieved  and  with  this  the  pancreas 
and  the  liver  are  simultaneously  reduced  to  a  normal  size. 

The  portion  of  the  gland  that  has  been  hopelessly  destroyed  is,  of 
course,  permanently  lost,  but  the  remaining  portions  are  usually  sufficient 
to  perform  the  necessary  physiologic  functions  if  the  patient  is  properly  edu- 
cated in  the  selection  of  food. 

Acute  Pancreatitis. 

It  is  difficult  to  make  a  differential  diagnosis  in  acute  pancreatitis  with 
any  degree  of  certainty  because  there  are  several  other  violent  acute  condi- 
tions which  are  so  similar  in  their  symptoms  that  they  can  probably  never 
be  positively  excluded.  The  conditions  most  likely  to  be  confounded  are 

(1)  perforation  of  the  posterior  wall  of  the  pyloric  end  of  the  stomach; 

(2)  perforation  or  gangrene  of  the  gall-bladder  or  duodenum. 

Cases  of  severe  acute  pancreatitis  have  been  diagnosed  as  acute  intestinal 
obstruction,  renal  colic,  ectopic  gestation  and,  of  course,  appendicitis  and 
gall-stone  colic. 

Symptoms. 

In  acute  pancreatitis  the  pain  is  extremely  severe  in  the  right  upper 
quadrant  of  the  abdomen.  There  is  intense  shock;  nausea  and  vomiting  are 
usually  present  and  the  patient  gives  the  impression  of  being  at  the  verge 
of  dissolution.  The  abdominal  muscles  are  tense,  although  Moynihan  found 
this  symptom  absent  in  some  of  his  cases.  There  is  usually  a  steady  rise 
of  the  pulse  from  the  onset. 


468  GENERAL    SURGERY    OF    THE    ABDOMEN 

In  these  cases  there  is  usually  a  history  pointing  to  gall-stone  colic 
in  previous  milder  attacks. 

If  a  tumor  be  felt  there  is  usually  tympanitis  on  percussion  over  this 
surface  because  the  gland  is  located  behind  the  duodenum. 

Cyanosis  has  been  observed  by  Opie  and  others.  Sugar  is  present  in 
the  urine  in  some  cases.  Egdahl  gives  a  careful  review  of  107  cases  in  his 
study  of  the  symptoms  and  diagnosis  of  acute  pancreatitis  which  is  well 
worth  the  careful  consideration  of  the  clinician. 

Surgical  Treatment  of  Acute  Pancreatitis. 

In  mild  cases  of  acute  pancreatitis  surgical  treatment'  is  not  indicated. 
If  the  local  irritation  is  removed  by  making  gastric  lavage  and  placing  the 
patient  on  exclusively  rectal  alimentation,  so  that  nothing  passes  through 
the  duodenum  for  a  time,  the  obstruction  to  drainage  through  the  common 
duct  will  soon  subside  because  of  the  disappearance  of  the  local  edema,  and 
then  the  conditions  will  be  favorable  for  recovery  from  acute  pancreatitis. 

The  correctness  of  this  view  must  be  plain  to  every  one  who  has  oper- 
ated on  a  large  number  of  patients,  suffering  from  acute  gall-stone  impaction 
in  the  common  and  cystic  ducts,  at  various  periods  during  these  attacks.  If 
an  operation  is  performed  during  the  attack  the  simple  drainage  of  the  gall- 
bladder has  always,  in  our  experience,  sufficed  to  relieve  the  condition,  ex- 
cept in  cases  in  which  there  existed  at  the  same  time  a  severe  acute  cholan- 
gitis,  in  which  there  has  been  a  mortality  of  about  30  per  cent.  A  moderate 
degree  of  cholangitis  will  subside  even  if  there  is  marked  acute  pancreatitis, 
provided  the  operation  itself  does  not  increase  the  infection. 

It  should  be  as  simple  as  possible  and  no  rough  or  unnecessary  handling 
of  the  inflamed  tissues  should  be  employed. 

Even  in  violent  acute  cases  of  pancreatitis  a  proportion  of  patients  will 
recover  if  the  abdomen  is  quickly  opened  and  simple  drainage  introduced. 
Glass  tubes  covered  with  gauze,  split  rubber  tubes  or  cigarette  drains  may 
be  employed.  The  number  of  recoveries  depends  on  the  severity  of  the 
attack  and  the  promptness  with  which  drainage  is  supplied.  Robson  has 
had  nearly  40  per  cent  of  recoveries.  Patients  in  whom  the  extravasation 
of  pancreatic  juice  has  caused  fat  necrosis  are  least  likely  to  recover.  We 
have  seen  several  of  these  patients  that  have  recovered  without,  and  one 
with,  operation  and  Mayo  reports  similar  results. 

Unless  jaundice  is  present  it  is  best  to  limit  the  operation  to  the  location 
and  drainage  of  circumscribed  areas  of  infection  or  necrosis  of  the  pancreas, 
to  the  control  of  hemorrhage  by  means  of  fine  catgut  sutures,  and  the  free 
drainage  of  the  entire  area.  This  can  best  be  done  through  a  median  or 
a  high  right  rectus  incision.  It  is  important  to  go  over  the  gland  carefully, 
but  it  is  quite  as  important  not  to  traumatize  the  tissues  unnecessarily.  These 
patients  have  but  a  slight  margin  of  possibility  of  recovery  and  this  can 
easily  be  lost  by  unnecessary  traumatism  or  prolonged  exposure. 

If  jaundice  is  present  simple  drainage  of  the  gall-bladder,  with  removal 
of  loose  gall-stones,  is  indicated,  but  it  is  best  not  to  interfere  with  stones 
impacted  in  the  ducts.  We  lost  two  patients  needlessly  before  appreciating 
the  folly  of  doing  too  much  in  these  cases. 

Conclusions. 

In  a  general  way  the  following  conclusions  seem  proper : 
i.     A  clinical  diagnosis  of  chronic  pancreatitis  is  usually  possible  before 
operation. 


GENERAL    SURGERY    OF    THE    ABDOMEN  469 

2.  This  condition  is  practically  always  a  complication  of  gall-bladder 
or  gall-duct  disease,  except  when  following  metastatic  infection. 

3.  It  is  usually  curable  by  relieving  the  pathologic  condition  of  the 
gall-bladder  and  ducts. 

4.  An  operative  diagnosis  of  acute  pancreatitis  can  often  be  made. 

5.  Early  operation  greatly  improves  the  prognosis. 

6.  It  is  important  to  reduce  to  a  minimum  the  trauma  in  these  cases. 

7.  The  important  factor  in  the  treatment  consists  in  the  establishment 
of  free  drainage. 

PANCREATIC  CYSTS. 

In  cysts  of  the  pancreas  resulting  from  a  total  occlusion  of  the  duct 
thereof,  usually  due  to  traumatism,  the  treatment  consists  in  making  an  in- 
cision either  in  the  median  line  or  through  the  rectus  abdominis  muscle. 
The  tumor  will  be  found  to  be  retro-peritoneal,  because  the  pancreas  is  a 
retro-peritoneal  organ.  The  surrounding  organs  are  tamponed  away  by 
means  of  moist  aseptic  pads,  then  the  cyst  wall  is  exposed  by  making  a 
slit  in  the  peritoneum.  The  cyst  is  then  tapped  with  a  trocar,  then  opened 
and  the  remaining  fluid  sponged  away  with  moist  pads.  Then  the  cavity 
of  the  cyst  is  tamponed  lightly  with  iodoform  gauze  and  the  edges  of  the 
wound  sutured  to  the  parietal  peritoneum  and  transversalis  fascia  in  the 
upper  angle  of  the  wound.  The  remaining  portion  of  the  wound  is  closed 
in  the  usual  manner. 

The  iodoform  gauze  is  later  gradually  removed.  If  there  is  no  secretion 
after  this  has  been  done  no  further  drainage  is  instituted,  but  if  secretion 
continues  a  drainage  tube  is  inserted  when  the  tampon  has  been  removed  and 
this  is  kept  in  place  until  the  discharge  subsides,  which  usually  occurs  in 
a  relatively  short  time,  the  cyst  becoming  obliterated  by  the  adhesion  of 
its  walls. 

HEMORRHOIDS. 

Those  suffering  from  hemorrhoids  usually  give  a  history  of  long-con- 
tinued, habitual  constipation.  The  patient's  occupation  is  usually  sedentary 
and  the  diet  complicated  and  unhygienic,  hemorrhoids  resulting  from  ob- 
struction to  the  return  circulation  through  the  hemorrhoidal  veins.  This  ob- 
struction may  be  local,  clue  to  accumulations  in  the  rectum,  or  to  the  pres- 
ence of  tumors  in  the  pelvis.  Pregnancy  is  a  common  cause,  or  it  may  be 
the  result  of  obstruction  in  the  hepatic  circulation. 

Diagnosis. 

There  is  a  history  of  suffering  from  a  sensation  of  fullness  in  the 
region  of  the  hemorrhoidal  veins.  This  may  be  accompanied  by  occasional 
hemorrhages,  which  give  temporary  relief  to  such  sensation.  If  the  condi- 
tion has  existed  for  a  prolonged  time  there  is  a  protrusion  of  mucous  mem- 
brane containing  distended  hemorrhoidal  veins  at  each  evacuation  of  the 
bowels.  These  masses  may  become  replaced  spontaneously,  or  may  have  to 
be  returned  mechanically.  Upon  digital  examination  soft  oval  masses  will  be 
felt,  varying  in  number  from  one  to  six  or  eight,  although  there  are  usual- 
ly not  more  than  three  or  four.  Some  of  these  masses  are  usually  larger 
than  others.  They  sometimes  acquire  considerable  size  rather  more  than  an 
inch  in  diameter.  In  manv  cases  there  is  a  constant  secretion  from  these  sur- 


47O  GENERAL    SURGERY    OF    THE    ABDOMEN 

faces,  giving  rise,  on  account  of  its  irritating  character,  to  an  eczema. 
After  the  hemorrhoids  have  existed  for  a  time,  the  patients  usually  complain 
of  a  constant  burning  sensation  in  this  region. 

Treatment. 

In  many  cases  simply  regulating  the  diet,  securing  a  regular  free  evacu- 
ation of  the  bowels  each  day,  and  applying  some  soothing  ointment  or  sup- 
pository, together  with  the  use  of  Sitz,  or  shower  baths,  will  result  in  re- 
lief. If,  however,  it  has  existed  for  a  long  time  this  will  usually  not  suf- 
fice, and  an  operation  will  have  to  be  employed  in  order  to  secure  perma- 
nent relief. 

The  patient  should  be  cautioned  to  eat  only  easily  digestible  food  in 
very  moderate  quantity,  to  take  a  mild  saline  laxative  every  day  for  several 
days  previous  to  undergoing  operation,  and  on  the  day  before  operation  he 
should  be  given  two  ounces  of  castor  oil,  followed  the  same  evening,  and 
the  following  morning,  with  large  flushings  of  the  colon.  In  this  manner  the 
alimentary  canal  can  be  quite  thoroughly  freed  from  material  which  might 
otherwise  irritate  the  wound  surfaces  after  the  operation. 

Operative  Technique. 

In  our  own  experience  the  following  operation  has  proved  exceedingly 
satisfactory  in  almost  every  case.  The  patient  being  anesthetized  and 
placed  in  the  lithotomy  position  the  sphincter  ani  muscles  are  very  thorough- 
ly dilated  by  introducing  the  thumbs  beyond  the  internal  sphincter  and 
stretching  very  slowly,  but  very  thoroughly.  The  slow  progress  of  the 
stretching  will  prevent  tearing  the  mucous  membrane  unnecessarily.  The 
stretching  should  be  continued  until  the  sphincter  remains  lax  after  it  has 
ceased.  Each  hemorrhoid  is  then  caught  with  two  pairs  of  hemostatic  for- 
ceps placed  in  a  straight  line  with  the  direction  of  the  rectum,  the  outer  one 
being  from  one  to  two  centimeters,  the  second  from  two  to  four  centimeters, 
from  the  margin  of  the  anus.  A  clamp  is  then  applied  to  the  hemorrhoid 
beneath  the  attachment  of  these  forceps,  also  in  the  direction  of  the  rectum. 
If  it  is  convenient  a  clamp  which  is  protected  on  its  lower  side  with  some  bad 
conductor  of  heat,  such  as  ivory,  bone  or  rubber,  is  to  be  preferred,  other- 
wise an  ordinary  pair  of  long-jawed  hemostatic  forceps  will  serve  the  pur- 
pose very  well.  The  surrounding  tissues  should  be  protected  by  placing 
underneath  the  forceps  a  piece  of  asbestos  cloth,  or  if  this  cannot  be  pro- 
cured, a  piece  of  gauze  folded  half  a  dozen  times  upon  itself  and  im- 
mersed in  cold  water  may  be  placed  underneath  the  clamp.  A  shield  may  be 
cut  out  of  ordinary  pasteboard  and  this  may  be  immersed  in  corrosive  sub- 
limate solution  for  a  moment  before  using.  This  is  slipped  between  the 
clamp  and  the  patient,  producing  a  perfect  protection  against  burning.  The 
projecting  portion  of  the  hemorrhoid  is  then  carefullv  seared  by  means  of  a 
cautery.  It  is  preferable  not  to  cut  away  the  projecting  portion,  and  to 
cauterize  the  small  portion  left  bevond  the  forceps,  because  if  the  entire 
hemorrhoid  is  thoroughly  baked  with  a  cautery  not  too  hot.  there  is  never 
any  danger  of  subsequent  bleeding,  which  is  not  the  case  when  the  top  of 
the  hemorrhoid  has  been  cut  off  first  and  the  cautery  applied  later.  Any 
cautery  will  serve  the  purpose,  but  the  one  which  we  have  found  of  the 
greatest  service  consists  in  a  simple,  small-sized  soldering  iron,  heated  in  a 
tinsmith's  heater,  in  an  ordinary  gas  flame,  in  a  coal  stove  or  over  an  alcohol 
lamp.  It  is  much  more  economical  than  any  of  the  gasoline  or  electric 
cauteries,  it  is  never  out  of  repair,  and  can  be  easily  procured  anywhere. 


PLATE  LXIV. 

CLAMP  AND  CAUTERY  OPERATION  FOR  HAEMORRHOIDS 

Showing  forceps  a  and  c  in  place  for  the  purpose  of  marking  hamorrhoidal 
tumors  at  beginning  of  operation ;  b  clamp  protecting  underlying  skin  by  means 
of  ivory  plates  riveted  to  lower  surface  of  jaw  plates. 


GENERAL    SURGERY    OF    THE    ABDOMEN  473 

The  successive  hemorrhoids  are  then  picked  up  in  the  same  manner 
and  treated  alike. 

The  main  vessels  come  down  in  three  groups,  one  anteriorly  and  two 
laterally.  If  these  are  caught  in  three  masses  and  cauterized,  the  remain- 
ing hemorrhoids  will  usually  disappear  spontaneously.  It  is  important 
in  applying  the  clamps  always  to  leave  at  least  half  an  inch  of  normal 
mucous  membrane  in  order  to  avoid  the  production  of  stricture. 

It  is  not  wise  to  cauterize  a  hemorrhoid  exactly  in  the  median  line  in 
front,  in  a  male,  on  account  of  its  close  proximity  to  the  urethra,  as  it  fre- 
quently happens,  if  this  is  done,  that  an  obstruction  to  the  passage  of  urine 
occurs  for  several  days  after  the  operation,  which  may  prove  exceedingly 
annoying;  and  if  a  hemorrhoid  at  some  small  distance  to  one  side  of  the 
median  line  is  caught  the  one  which  may  exist  exactly  in  the  median  line,  and 
which  may  be  larger  than  either  of  the  others,  will  disappear  spontaneously. 
It  happens  occasionally  that  there  is  but  one  hemorrhoid,  and  that  this  is 
just  in  the  median  line ;  then,  of  course,  it  will  have  to  be  clamped  in  order 
to  secure  relief.  It  is  of  very  great  importance  that  if  the  clamp  and  cautery 
method  is  used  the  clamp  should  always  be  applied  parallel  with  the  direc- 
tion of  the  rectum,  because  if  it  is  applied  transversely  the  patient  is  almost 
certain  to  suffer  from  the  formation  of  a  stricture. 

In  selecting  a  clamp  it  is  well  to  avoid  an  instrument  with  sharp  serra- 
tions, as  these  would  be  likely  to  injure  the  delicate  veins,  giving  rise  to 
troublesome  hemorrhage.  Even  with  a  properly  constructed  clamp  care 
must  be  taken  not  to  lacerate  the  veins. 

Ligature  Method. 

If  no  clamp  of  any  kind  is  available,  and  it  is  desirable  to  relieve  a  pa- 
tient of  hemorrhoids,  this  may  be  accomplished  by  the  following  plan, 
which  we  believe  is  quite  as  satisfactory  as  the  clamp  and  cautery  method, 
but  we  have  not  performed  it  nearly  so  often,  having  become  accustomed  to 
the  other  procedure. 

The  preparatory  method  and  dilatation  are  the  same  as  in  the  opera- 
tion just  described.  The  hemorrhoid  is  picked  up  in  the  same  manner.  It 
is  then  transfixed  with  a  needle  armed  with  double  silk  or  cat-gut  ligature, 
about  thirty  to  forty  centimeters  in  length.  The  needle  is  cut  away  and  the 
ligature  tied  upwards  underneath  the  second  forceps.  With  scalpel  or  scis- 
sors the  mucous  membrane  is  then  carefully  cut  transversely  at  the  margin 
of  the  anus  and  the  second  ligature  is  tied  in  the  groove  thus  formed.  The 
projecting  portion  of  the  hemorrhoid  is  then  cut  away,  only  a  sufficient 
amount  being  left  to  prevent  slipping  of  the  ligature.  This  method  is  ap- 
plied to  each  hemorrhoid  in  succession  until  all  have  been  removed. 

Dressings. 

The  patient  is  much  more  comfortable,  and  the  wound  will  heal  quite  as 
satisfactorily,  if  no  dressing  is  applied  after  either  the  clamp  and  cautery  or 
the  ligature  method.  For  a  considerable  time  we  habitually  applied  some 
form  of  tampon  or  drainage  to  the  rectum  after  operating  for  hemorrhoids. 
This  was  decreased  in  amount  constantly  with  increasing  comfort  to  the 
patient,  until  at  last  we  discarded  this  form  of  dressing  entirely,  and  latterly 
for  a  large  number  of  these  cases  no  dressing  has  been  used,  except  a  little 
ordinary  pad  to  the  external  parts  held  in  place  by  a  T  bandage,  for  the 
purpose  of  absorbing  any  secretion. 


474  GENERAL    SURGERY    OF    THE    ABDOMEN 

After-treatment. 

The  patient  is  kept  on  liquid  diet  for  four  or  five  days.  At  the  end  of 
this  time  a  cathartic  is  given  and  before  this  causes  an  evacuation  a  large 
soap  and  water  enema  is  administered  through  a  soft  rubber  catheter.  This 
is  repeated  after  the  cathartic  has  acted.  From  this  time  on  a  small  saline 
laxative  is  given  every  morning,  and  the  evacuation  is  followed  by  the  soap 
and  water  enema.  The  patient  is  confined  to  his  bed  for  about  a  week. 

In  unusually  severe  cases  the  excision  of  the  entire  rim  of  hemorrhoidal 
tumors  may  be  practised,  although  this  is  but  very  rarely  necessary.  Even 
in  very  extensive  cases  the  results,  after  the  application  of  the  clamp  and 
cautery  to  three  or  four  of  the  largest  hemorrhoids,  are  very  satisfactory, 
the  others  disappearing  shortly  after  the  operation.  In  case,  however,  it 
seems  desirable  to  choose  a  still  more  thorough  operation  the  following  will 
bring  a  satisfactory  outcome. 
Radical  Operation. 

An  incision  is  made  at  the  margin  of  the  anus  and  the  mucous  mem- 
brane, together  with  the  enlarged  hemorrhoidal  veins,  dissected  out  care- 
fully for  a  distance  of  two  to  four  centimeters.  The  mucous  membrane  is 
then  drawn  down  from  above  and  about  eight  interrupted  cat-gut  sitches 
are  applied  at  regular  intervals,  reaching  through  all  the  coats  of  the  intes- 
tine down  to  the  mucous  membrane,  but  not  through  it,  and  through  the 
subcutaneous  connective  tissue  at  the  margin  of  the  anus.  These  stitches 
should  be  so  applied  that  after  the  portion  of  the  rectum  containing  the 
hemorrhoids  has  been  cut  away  there  will  be  still  a  slight  projection  of  the 
mucous  membrane  of  the  rectum  beyond  the  margin  of  the  anus.  All  bleed- 
ing points  are  caught  during  the  operation  and  carefully  ligated  with  fine 
cat-gut.  After  the  intestine  has  been  sutured  in  place  in  this  manner  the 
projecting  portion  is  cut  away  and  the  mucous  membrane  of  the  intestine 
sutured  accurately  to  the  skin,  the  normal  portion  projecting  a  little  beyond 
the  margin  of  the  latter.  If  the  eight  stay  sutures  which  were  first  applied 
are  carefully  placed  their  pressure  will  control  the  hemorrhage  from  the 
hemorrhoidal  veins,  so  there  will  be  no  bleeding  when  the  projecting  portion 
is  cut  away. 

The  treatment  after  this  operation  is  the  same  as  after  the  operations 
which  have  been  just  described. 

This  last  operation  is  very  attractive,  but  in  the  vast  majority  of  cases 
it  is  unnecessary. 

Prognosis. 

It  does  not  matter  which  operation  is  chosen,  the  prognosis  will  largelv 
depend  upon  the  hygienic  conditions  the  patient  provides  for  himself.  If 
proper  food  is  taken,  if  constipation  is  avoided,  and  if  proper  exercise  is  en- 
joyed, the  patient  will  remain  permanently  cured,  which  is  not  likely  if  these 
conditions  are  neglected. 

FISSURE  IN  ANO. 

One  of  the  most  painful  affections,  and  which  frequently  accompanies 
the  presence  of  hemorrhoids,  or  is  secondary  to  the  latter,  is  fissure  in  ano, 
which  is  a  small  lesion  extending  parallel  with  the  rectum,  and  consequentlv 
at  right  angles  with  the  sphincter  ani  muscles.  It  is  this  last  fact  which 
causes  this  condition  to  resist  treatment,  as  the  wound  constantly  gives  rise 


GENERAL    SURGERY    OF    THE    ABDOMEN  475 

to  spasmodic  contractions  of  the  sphincter  ani  muscles,  and  these  in  turn 
crush  the  surface  which  is  already  sore.  The  evacuation  of  the  bowels  is 
likely  to  open  the  wound,  which  may  have  begun  to  heal  during  the  inter- 
val, and  the  accompanying  pain  gives  rise  to  spasmodic  contraction  of  the 
sphincter  muscles ;  consequently  the  patient  suffers  severely  for  some  time 
after  the  bowels  have  been  evacuated.  The  application  of  remedies  is  of 
very  little  benefit,  for  the  reasons  just  mentioned.  Unless  the  condi- 
tion is  but  very  slight  an  operation  must  usually  be  resorted  to  before  the 
patient  can  be  properly  and  completely  relieved. 

Technique. 

The  operation  in  moderate  cases  consists  simply  in  thoroughly  dilating 
the  sphincter  ani  muscles  so  that  the  wound  may  remain  at  rest  for  a  few 
days.  At  the  end  of  this  time  it  will  have  healed  spontaneously.  If,  how- 
ever, the  fissure  has  existed  for  a  number  of  months,  or  years,  the  amount 
of  cicatricial  tissue  formed  along  its  course  may  be  considerable,  and  then 
the  simple  operation  of  stretching  the  sphincter  ani  muscle  may  no  longer 
suffice  to  give  relief.  In  such  case  the  muscles  should  be  stretched  very  thor- 
oughly, and  then  the  cicatricial  tissue  excised  and  the  mucous  membrane 
brought  down  from  above  and  attached  to  the  wound  at  the  margin  of  the 
anus  with  a  few  fine  cat-gut  sutures.  This  simple  method  has,  in  our  ex- 
perience, resulted  in  the  relief  of  even  very  severe  cases  which  had  existed 
for  a  long  time. 

The  after-treatment  is  the  same  as  in  operation  for  hemorrhoids. 

FISTULA  IN  ANO. 

It  is  but  rarely  that  one  suffering  from  fistula  in  ano  comes  under  the 
care  of  a  surgeon  during  the  early  part  of  his  disease.  He  has  usually  suf- 
fered for  months,  or  years,  and  has  made  use  of  various  local  remedies  with- 
out benefit. 

History. 

The  patient  gives  a  history  of  having  suffered  from  an  acute  infection 
in  the  ischio-rectal  fossa,  which  resulted  in  an  abscess,  variable  in  size, 
opening  spontaneously  or  by  an  incision.  Before  the  occurrence  of  this  in- 
fection there  is  generally  a  history  of  hemorrhoids.  There  has  usually  been 
a  discharge  of  pus  from  the  opening  for  a  considerable  time,  during  which 
the  patient  is  fairly  free  from  pain.  Then  the  opening  would  close  and 
there  would  be  a  reaccumulation  of  pus  within  the  abscess,  again  provoking 
much  suffering.  These  events  may  have  existed  for  a  greater  or  less  ex- 
tent of  time,  and  there  may  have  been  a  variable  number  of  reaccumulations 
of  pus.  There  may  be  one  or  a  number  of  external  openings.  Quite  a 
considerable  proportion  of  these  cases  give  a  history  of  cough,  and  upon 
examination  some  evidence  of  pulmonary  tuberculosis  may  be  established. 

The  usual  practice  of  introducing  a  probe  into  one  of  these  fistulse  is, 
we  believe,  to  be  condemned,  because  it  gives  rise  to  an  amount  of  pain,  it 
may  produce  a  new  infection,  and  it  does  not  afford  the  surgeon  any  infor- 
mation which  he  cannot  obtain  by  simply  looking  at  the  external  surface, 
and  by  making  a  digital  examination. 

Technique. 

The  treatment  should  invariably  be  surgical,  although  long-continued 


476 


GENERAL    SURGERY    OF    THE    ABDOMEN 


applications,  curettements  and  irrigations  may,  in  very  rare  cases,  result  in 
a  cure  of  the  rectal  fistula ;  still  these  cases  are  so  rare  that  it  is  much  bet- 
ter to  invariably  proceed  to  the  radical  surgical  treatment  as  soon  as  the 
consent  of  the  patient  can  be  obtained. 

The  preparatory  treatment  should  be  the  same  as  that  described  for 
hemorrhoid  operation.  The  patient  is  anesthetized  and  the  sphincter  ani 
muscles  dilated.  Then  a  grooved  director  is  inserted  into  the  fistula  from 
without  and  the  finger  within  the  rectum  feels  for  a  little  projection  in  the 
form  of  a  granulation,  readily  found  in  quite  a  large  proportion.  By  care- 
fully manipulating  the  grooved  director  it  will  find  its  way  along  the  fistula 
to  a  point  opposite  this  granulation,  through  which  it  can  be  pushed  into  the 
rectum.  Then  an  incision  is  made  directly  through  all  of  the  tissues  between 
the  grooved  director  and  the  rectum.  Sharp  retractors  are  placed  in  the 
edges  of  the  wound  and  the  granulations  carefully  curetted  away.  If  the 
surgeon  looks  for  prolongations  of  the  fistula,  even  these,  too,  in  case  they 
exist,  end  in  a  little  granulation  tissue  projecting  into  the  sinus  which  has 
been  curetted.  By  looking  for  this  little  granulation  one  can  feel  all  the 
various  sinuses,  and  by  laying  them  open  freely  and  curetting  away  the 
granulation  tissue,  obtain  a  perfectly  clean  wound.  If  the  fistulae  have 


FIG.  19. 
1.   Blind    external    fistula.     2.  Complete    fistula.     3.   Blind    internal    fistula. 

burrowed  through  the  tissues  beyond  the  sphincter  ani  muscles  in  various 
places  the  latter  should  not  be  severed  except  at  the  point  of  the  first  in- 
cision, for  fear  of  having  the  patient  lose  control  over  the  action  of  the 
bowels  and  the  passage  of  gas.  In  case  the  fistula  has  existed  for  a  long 
time  the  cicatricial  tissue  formed  should  be  dissected  away  with  a  sharp 
scalpel,  in  order  to  leave  the  surface  perfectly  free  and  to  have  all  por- 
tions of  the  wound  as  clean-cut  surfaces.  If  all  of  the  infected  tissue  has 
been  removed,  the  course  to  be  followed  may  consist  in  tamponing  the  raw 
surface  with  iodoform  gauze,  to  be  left  in  place  for  a  number  of  days,  and 
then  replaced  daily  after  evacuation  of  the  bowels,  or  the  surface  may  be 
closed  by  suturing.  The  latter  method  should  only  be  chosen  when  the 
surgeon  is  absolutely  certain  that  all  portions  of  the  infected  tissue  have 
been  thoroughly  removed.  Then  deep,  silk-worm  gut  sutures  may  be  in- 
serted so  they  are  buried  throughout  their  entire  extent,  entering  the  tissues 


GENERAL    SURGERY    OF    THE    ABDOMEN  477 

at  a  point  half  an  inch  from  the  edge  of  the  original  wound,  passing  en- 
tirely around  the  area  of  the  wound  and  issuing  on  the  opposite  side  half 
an  inch  from  the  edge  of  the  original  incision.  The  mucous  membrane  of 
the  rectum  may  be  sutured  separately  with  a  row  of  cat-gut  sutures,  the 
silkworm  sutures  remaining  untied  in  the  meantime.  If  the  sphincter  ani 
muscles  have  been  cut  a  few  cat-gut  sutures  may  be  passed  through  them 
and  tied  separately.  Then  the  deep  silk-worm  gut  sutures  are  tied  over  all 
and  a  few  coaptation  stitches  applied  to  the  skin.  This  method  will  suc- 
ceed in  healing  most  of  the  simple  fistulse  within  ten  days  or  two  weeks ;  at 
the  end  of  which  time  the  deep  silk-worm  gut  sutures  are  removed. 

After-treatment. 

The  after-treatment  is  the  same  as  in  operation  for  hemorrhoids.  If, 
however,  the  wound  has  not  been  closed  with  sutures  an  enema  should  be 
given  after  each  evacuation  of  the  bowels,  and  then  the  iodoform  gauze  tam- 
pon again  applied  to  the  wound,  in  order  to  compel  the  latter  to  heal  from 
the  bottom. 

PROLAPSE  OF  THE  RECTUM. 

This  occurs  more  frequently  in  childhood  than  during  any  other  period. 
It  is  usually  the  result  of  straining  due  to  constipation,  or  on  account  of 
phimosis  in  young  children,  or  because  of  the  presence  of  a  fissure,  giving 
rise  to  tenesmus.  The  mucous  membrane  of  the  rectum  usually  prolapses 
during  the  evacuation  of  the  bowel  and  it  becomes  difficult  and  painful  to 
replace  it. 

Technique. 

If  one  of  the  causes  mentioned  still  exists,  it  should  be  relieved  and  the 
condition  treated  in  a  non-surgical  way  at  first.  The  patient  should  be 
placed  in  the  inverted  position  and  gentle  pressure  made  upon  the  prolapsed 
portion,  and  a  suppository  composed  of  cocoa  butter,  some  mild  antiseptic 
substance,  and  some  astringent  substance,  should  be  inserted  into  the  bowel. 
The  lower  end  of  the  child's  bed  should  be  elevated  so  as  to  add  the  benefit 
of  gravitation  to  the  treatment.  If  this  form  of  treatment  does  not  suc- 
ceed in  relieving  the  child,  he  should  be  anesthetized,  the  sphincter  ani  mus- 
cles very  gently  dilated,  and  then  the  treatment  with  clamp  and  cautery, 
described  under  the  head  of  hemorrhoids,  should  be  employed,  with  the  ex- 
ception that  only  a  very  small  depth  of  tissue  should  be  caught  by  the 
clamp,  and  also  that  the  eschar  extend  a  distance  of  three  or  four  centi- 
meters along  the  lower  end  of  the  bowel.  Three,  or  at  least  four,  longi- 
tudinal eschars  will  almost  always  suffice  to  relieve  a  prolapse  in  children. 
Of  course,  the  same  care  should  be  exercised  to  have  the  eschars  extend 
parallel  with  the  bowel,  insisted  upon  in  connection  with  the  clamp  and 
cautery  operation  for  hemorrhoids. 

In  Severe  Forms. 

In  the  adult  prolapse  frequently  follows  the  long-continued  existence 
of  hemorrhoids,  and  usually  the  relief  of  the  latter  will  result  in  the  relief 
of  the  prolapse.  In  rare  instances  it  happens,  however,  that  neither  of  the 
operations  described  for  the  relief  of  hemorrhoids  could  promise  any  relief 
in  this  condition  because  the  entire  wall  of  the  intestine  may  have  prolapsed 
through  the  anus  for  a  distance  of  a  number  of  inches.  In  this  event  the 
prolapse  should  be  reduced,  after  the  preparations  described  in  connection 


478  GENERAL    SURGERY    OF    THE    ABDOMEN 

with  hemorrhoid  operations  have  been  carried  out.  The  patient  should  be 
placed  in  bed,  with  the  foot  of  the  bed  elevated  from  six  to  ten  inches.  This 
position  is  kept  for  a  variable  period,  depending  upon  the  severity  of  the 
prolapse — from  one  or  two  days  to  as  many  weeks — in  order  to  disperse  the 
edema  which  may  exist  in  the  intestine.  Then  an  abdominal  section  is  made 
through  the  median  line  and  the  lower  end  of  the  sigmoid  flexure  is  found 
and  carried  to  the  left  side  of  the  abdominal  cavity  and  stitched  by  means 
of  a  considerable  number  of  fine  silk  sutures  directly  to  the  abdominal  wall 
a  little  in  front  of  its  normal  location.  In  this  manner  the  entire  rectum 
and  the  lower  end  of  the  sigmoid  flexure  will  be  carried  upwards  sufficiently 
to  prevent  recurrence  of  the  prolapse.  The  sphincter  ani  muscles  should 
be  very  thoroughly  stretched  so  as  to  prevent  any  obstruction  to  the  pas- 
sage of  gas  and  feces  until  the  intestine  has  become  firmly  united  with  the 
parietal  peritoneum. 

If  the  sigmoid  is  drawn  upwards,  when  the  abdomen  is  opened  with 
the  patient  lying  in  the  Trendelenburg  position,  the  prolapsing  peritoneal 
pouch  can  be  seen  and  obliterated  with  interrupted  silk  sutures,  which  will 
give  the  rectum  a  very  substantial  support. 

It  is  important  that  a  non-absorbable  suture  be  used,  because  if  the  in- 
testine is  sutured  with  ordinary  cat-gut  the  adhesions  will  be  likely  to  absorb 
and  the  patient  suffer  from  a  recurrence,  while  if  silk  or  chromicized  cat-gut 
is  employed  this  cannot  occur.  The  bowels  should  be  carefully  regulated 
after  this  operation,  so  that  there  never  is  too  great  an  accumulation  in  the 
large  intestine. 

All  other  causes  of  intra-abdominal  pressure  should  also  be  overcome. 
If  there  is  an  obstruction  to  the  passage -of  urine  due  to  the  presence  of  a 
stricture  or  enlargement  of  the  prostate  gland,  it  should  be  relieved.  If  the 
patient  is  suffering  from  a  great  accumulation  of  fat  in  the  omentum,  mesen- 
tery and  abdominal  walls,  it  should  be  relieved  by  proper  diet  and  exercise. 
If  all  of  these  precautions  are  carried  out  a  recurrence  is  not  likely. 

CARCINOMA  OF  THE  RECTUM. 

Patients  suffering  from  carcinoma  of  the  rectum  usually  give  a  history 
of  long-continued  irregularity  in  the  evacuation  of  the  bowels.  At  first  there 
is  usually  long  continued  constipation ;  then  this  is  interrupted  by  occasional 
attacks  of  djarrhea;  then  a  history  of  the  evacuation  of  ribbon-like  forma- 
tions of  feces,  indicating  some  constriction  in  the  rectum,  and  later  on 
there  is  usually  complete  temporary  obstruction  which  may  exist  for  only 
a  short  time  at  first  and  may  recur  at  various  intervals,  or  the  patient  may 
come  under  the  observation  of  the  surgeon  during  the  first  one  of  these  at- 
tacks of  obstruction.  In  most  cases  there  is  a  passage  of  thick  mucus,  either 
with  the  bowel  evacuation  or  during  the  interval  between  evacuations.  In 
many  cases  there  is  also  a  slight  amount  of  hemorrhage,  and  very  rarely 
one  of  these  patients  suffers  from  a  severe  hemorrhage  from  the  rectum. 

Upon  examination  a  hard,  nodular  mass  is  felt  in  the  rectum,  usually 
with  a  small  central  opening,  or  the  mass  may  be  upon  one  side  of  the  rec- 
tum and  on  the  other  the  mucous  membrane  may  be  normal.  The  sensation 
to  the  touch  of  a  carcinoma  of  the  rectum  is  so  characteristic  that  if  a  sur- 
geon has  once  experienced  it  he  will  have  no  difficulty  thereafter  in  its  rec- 
ognition. It  differs  from  the  feeling  of  a  stricture  because  of  the  nodular 
character,  and  because  of  the  tumor-like  projection  of  the  mass,  while  a 


GENERAL    SURGERY    OF    THE    ABDOMEN  479 

cicatricial  stricture  simply  presents  the  sensation  of  a  narrowing  of  the 
canal.  It  differs  from  a  tubercular  stricture  from  the  fact  that  although  the 
latter  also  is  nodular  in  character  it  does  not  give  the  impression  of  a  tumor- 
like  projection. 

Technique. 

If  the  carcinoma  is  in  the  lowest  portion  of  the  rectum,  does  not  extend 
above  the  cul-de-sac  of  Douglas,  and  is  movable,  the  treatment  should  con- 
sist in  the  excision  of  the  entire  mass,  together  with  the  surrounding  tissues 
to  as  great  an  extent  as  possible.  The  incision  through  the  skin  should  be 
free,  should  pass  up  behind  to  the  lower  edge  of  the  sacrum,  should  include 
the  coccyx,  and  the  entire  mass  should  be  loosened  from  its  attachment  in 
one  piece,  so  as  to  avoid  the  implantation  of  carcinomatous  tissue  during  the 
operation.  The  rectum  should  be  freed  for  a  distance  of  at  least  two  inches 
beyond  the  upper  margin  of  the  carcinoma,  two  pairs  of  strong  forceps 
should  be  applied  to  the  bowel  at  this  point,  and  the  latter  severed  between 
these  forceps  and  the  tumor  thus  removed.  The  bleeding  vessels  should 
be  caught  during  the  operation,  so  that  the  loss  of  blood  will  be  reduced  to  a 
minimum,  and  from  time  to  time  all  of  these  vessels  thus  caught  should  be 
ligated  so  as  to  leave  the  field  of  operation  as  free  from  obstruction,  on  ac- 
count of  the  presence  of  hemostatic  forceps,  as  possible.  The  upper  segment 
of  the  intestine  should  then  be  freed  sufficiently  so  that  it  can  be  brought 
into  the  upper  angle  of  the  wound  and  carefully  sutured  to  the  skin. 

We  have  never  encountered  a  carcinoma  of  the  rectum  in  which  it 
seemed  safe  to  preserve  the  sphincter  ani  muscles.  In  a  few  cases  in 
which  we  have  attempted  to  remove  the  malignant  growth  and  to  attach  the 
upper  segment  of  the  intestine  to  the  lower  segment,  thus  preserving  the 
sphincter  ani  muscles,  there  has  been  a  recurrence,  but  in  the  vast  majority  of 
cases  the  fact  that  a  recurrence  would  follow  was  so  plain  at  the  time  of  the 
operation  that  the  preservation  of  the  sphincter  ani  muscles  was  not  under- 
taken. 

If  carcinoma  of  the  rectum  is  so  far  advanced  that  a  rapid  recurrence 
would  be  inevitable  in  case  of  its  excision,  \vhich  can  usually  be  predicted 
when  the  tumor  is  removed,  then  we  believe  it  is  much  wiser  simply  to  do 
an  inguinal  colostomy,  already  described  in  the  section  on  abdominal  surgery. 

In  case  the  carcinoma  is  in  the  upper  portion  of  the  rectum,  or  in  the 
lower  portion  of  the  sigmoid  flexure,  then  the  operation  described  under  the 
head  of  abdominal  surgery  should  be  performed.  In  the  female  it  often 
occurs  that  the  carcinoma  is  upon  the  anterior  surface  of  the  rectal  wall  and 
has  attacked  the  recto-vaginal  septum ;  then  the  posterior  vaginal  wall 
should  be  removed,  together  writh  the  entire  rectum,  after  the  method  above 
described. 

The  after-treatment  is  the  same  as  in  operations  for  hemorrhoids,  with 
the  exception  that  the  wound  should  be  dressed  daily  in  order  to  prevent  its 
infection. 

Prognosis. 

Where  the  carcinoma  has  not  perforated  any  portion  of  the  intestine, 
the  prognosis  is  relatively  good,  provided  the  amount  of  tissue  removed  is 
quite  as  extensive  as  though  the  case  were  advanced  in  its  development.  In 
advanced  cases  the  prognosis  is  not  good,  without  regard  to  the  operation 
chosen.  In  our  experience  the  cases  in  which  permanent  inguinal  colostomy 


480  GENERAL    SURGERY    OF    THE    ABDOMEN 

was  made  prior  to  the  excision  of  the  carcinoma  have  lived  longer  than  those 
in  which  the  feces  were  permitted  to  pass  through  the  rectum  after  the  ex- 
cision of  the  growth. 

If  it  seems  possible  to  secure  a  radical  removal  of  the  carcinoma  by 
including  a  portion  of  the  vaginal  wall  the  following  steps  should  be  taken 
in  the  operation.  Long,  narrow  retractors  are  introduced  to  each  side  into 
the  vagina  in  order  to  expose  its  posterior  wall  freely,  then  an  elliptical 
incision  is  made  to  include  the  entire  posterior  vaginal  wall.  The  bleeding 
vessels  are  carefully  caught  and  ligated  and  the  incision  carried  backward 
on  each  side  and  around  the  anus  a  distance  of  at  least  4  cm.  from  the  anal 
orifice.  The  two  incisions  will  meet  opposite  the  tip  of  the  coccyx.  From 
this  point  a  median  incision  is  carried  upward  to  a  point  3  cm.  above  the 
lower  end  of  the  sacrum.  At  this  point  the  wound  is  held  open  by  means  of 
retractors  and  the  coccyx  separated  from  its  attachment  to  the  sacrum  by 
means  of  a  chisel.  This  bone  is  left  attached  to  the  rectum,  with  which  it  is 
removed.  It  is  not  uncommon  to  find  just  in  front  of  the  coccyx,  or  in 
front  of  the  sacrum,  one  or  more  infected  lymph  glands,  and  great  care 
should  be  exercised  in  removing  the  tissues  at  this  point.  The  entire  tumor, 
together  with  the  surrounding  tissues,  is  now  dissected  out,  care  being  taken 
to  grasp  the  bleeding  vessels  as  soon  as  they  are  severed,  especially  the 
branches  of  the  internal  pudic  artery  and  the  hemorrhoidal  veins,  in  order 
to  reduce  the  shock  from  hemorrhage  to  a  minimum.  This  leaves  the  entire 
mass  dissected  out  and  only  attached  above  to  the  healthy  intestine. 

The  intestine  is  then  at  once  grasped  by  two  pair  of  hemostatic  forceps 
at  least  4  cm.  above  the  upper  margin  of  the  tumor.  By  cutting  the  intes- 
tine between  these  the  tumor  can  be  removed  without  danger  of  soiling  the 
wound.  The  upper  segment  is  now  carefully  loosened  so  it  can  be  brought 
down  without  tension.  It  is  important  to  clamp  the  tissues,  in  doing  this, 
before  they  are  severed,  with  the  hemostatic  forceps  in  order  to  prevent 
dangerous  hemorrhage.  These  tissues  are  carefully  ligated  after  the  in- 
testine has  been  thoroughly  loosened.  Then  the  intestine  is  brought  down 
and  sutured  to  the  posterior  margin  of  the  incision.  It  is  important  to  carry 
the  intestine  at  least  3  cm.  beyond  the  margin  of  the  skin  because  if  this 
precaution  is  not  taken  it  is  almost  certain  to  retract,  and  if  it  retracts  with- 
in the  margin  of  the  skin  a  stricture  is  sure  to  occur.  Here,  as  in  all  cases 
in  which  a  tubular  stricture  is  brought  to  the  surface,  it  is  best  to  apply  a 
number  of  sutures  several  cm.  back  from  the  outer  surface  for  the  purpose 
of  attaching  the  intestine  to  the  wound  surface,  through  which  it  is  carried. 
Retraction  of  the  intestine  is  much  less  likely  to  occur  if  this  precaution  is 
taken.  Aside  from  this  it  is  well  to  apply  at  least  four  sutures  2  cm.  from 
the  margin  of  the  intestine  to  the  skin,  and  the  same  number  directly  be- 
tween the  margin  and  the  skin. 

THE  COMBINED  ABDOMINAL  AND  PERNEAL  METHOD  OF  REMOV- 
ING CARCINOMA  OF  THE  RECTUM. 

Where  the  carcinoma  of  the  rectum  extends  upward  too  far  to  be  com- 
pletely removable  from  below,  it  is  well  to  begin  the  operation  after  the 
method  just  described,  loosening  the  rectum  from  below  together  with  the 
tumor,  removing  the  lymph  nodes  and  fat  and  thoroughly  controlling  the 
hemorrhage.  Then  the  entire  space  should  be  thoroughly  tamponed  with 
gauze  and  covered  with  sterile  towels. 


GENERAL    SURGERY    OF    THE    ABDOMEN  481 

The  patient  is  then  placed  in  the  exaggerated  Trendelenburg  position 
and  a  large  median  abdominal  incision  made  extending  from  the  pubis  to 
the  umbilicus.  The  sigmoid  is  brought  into  the  wound  and  the  point  de- 
termined sufficiently  far  above  the  tumor  to  prevent  recurrence.  Two 
clamps  are  applied  at  this  point  and  the  sigmoid  cut  between  them. 

The  upper  end  is  covered  with  gauze  and  the  lower  segment  carefully 
dissected  out  by  applying  forceps  successively  to  the  vessels  entering  the 
intestine. 

This  dissection  is  carried  on  until  the  portions  of  the  sigmoid  and  rec- 
tum have  been  completely  dissected  out,  when  this  will  be  removed  together 
with  the  tumor.  All  of  the  fat  and  the  lymph  nodes  are  then  dissected  out 
with  gauze  dissection,  then  all  of  the  vessels  are  ligated,  the  wound  is 
drained  downward  with  cigarette  and  gauze  drainage  and  the  entire  sur- 
face covered  with  peritoneum. 

The  upper  segment  of  the  sigmoid  is  then  passed  through  the  ab- 
dominal wall,  according  to  the  method  described  under  inguinal  colostomy, 
and  the  abdominal  wall  is  closed. 

If  the  tumor  is  fairly  circumscribed,  the  prognosis  is  good  after  this 
operation. 

TUMORS  OF  THE  ABDOMINAL  WALL. 

Lipoma. 

Fatty  tumors  are  occasionally  found  in  the  abdominal  walls  and  can 
be  removed  without  danger  by  simply  making  an  incision  down  to  the 
growth,  enucleating  it,  and  closing  the  wound  in  the  skin. 

Fibro-sarcoma. 

Fibro-sarcomata  frequently  occur  in  the  abdominal  walls,  taking 
their  origin  from  any  one  of  the  various  fasciae ;  hence  their  name,  desmo-ids. 
These  tumors  usually  follow  severe  straining  during  labor  and  most  com- 
monly occupy  the  lower  end  of  the  abdominal  muscles. 

They  should  be  removed  freely,  a  considerable  amount  of  the  surround- 
ing tissue  being  sacrificed.  This  usually  involves  one  or  more  of  the  im- 
portant muscles  of  the  abdominal  wall  which  must  be  replaced  by  a  plastic 
operation  consisting  in  the  splitting  of  other  portions  of  the  abdominal  wall 
and  overlapping.  Fortunately  these  tumors  are  relatively  not  very  malig- 
nant, and  a  number  have  been  permanently  cured  by  removal.  It  is  usually 
well  for  patients  to  wear  some  form  of  abdominal  supporter  after  recover- 
ing from  this  operation. 

ABSCESSES  IN  THE  ABDOMINAL  WALL. 

Abscesses  in  the  abdominal  wall  sometimes  follow  traumatism,  but  more 
frequently  result  from  an  infection  within  the  peritoneal  cavity  which  has 
perforated  a  portion  of  the  abdominal  wall,  from  infections  of  the  ribs 
which  have  burrowed  downward,  from  empyemata  of  the  chest  which  have 
burrowed  downward,  or  from  tubercular  abscesses  of  the  spine  which  have 
followed  some  portion  of  the  transversalis  fascia.  The  intra-peritoneal  origin 
of  these  abscesses  is  most  commonly  the  vermiform  appendix.  Fallopian 
tube,  gall  bladder,  stomach,  kidney,  or  urinary  bladder.  Foreign  bodies, 
such  as  needles,  nails  or  sharp  bones,  may  penetrate  any  portions  of  the  ali- 


482  GENERAL    SURGERY    OF    THE    ABDOMEN 

mentary  canal  and  through  adhesions  of  these  to  the  abdominal  wall,  pene- 
trate the  latter  and  give  rise  to  abscesses. 

Treatment. 

If  the  abscess  is  not  tuberculous  in  character  it  is  best  to  lay  it  widely 
open,  curette  away  all  granulation  tissues  carefully,  and  by  looking  for  small 
areas  in  which  granular  tissue  persists,  one  can  usually  follow  the  abscess 
to  the  point  from  which  the  infection  originated.  If  this  can  be  done  and 
the  cause  removed  with  safety,  it  is  well.  If  the  origin  of  the  infection  can- 
not be  found  it  is  best  to  tampon  the  abscess  cavity  widely  open  and  at  the 
future  dressings  look  for  the  source  of  infection,  which  can  be  determined 
from  the  fact  that  at  some  point  there  will  be  a  new  accumulation  of  pus. 
Often  during  the  original  operation  the  source  of  infection  may  be  deter- 
mined by  making  pressure  upon  the  surrounding  portions  of  the  abdominal 
wall  and  watching  for  some  point  from  which  pus  shows  upon  such  pres- 
sure. 

Thoroughness  in  exploration  is  the  foundation  of  success  in  operation 
for  the  relief  of  this  condition.  If  it  does  not  seem  safe  to  follow  the  infec- 
tion to  its  point  of  origin  at  the  first  operation,  it  is  often  best  to  tampon 
the  abscess  cavity  and  later  approach  the  condition  from  the  abdominal 
cavity  through  a  new  incision,  the  location  of  infection  having  been  deter- 
mined by  the  primary  operation. 

INFECTION  OF  THE  UMBILICUS. 

Frequently  in  infants,  and  occasionally  in  the  adult,  infection  of  the 
umbilicus  occurs,  which  may  result  simply  in  a  slight  superficial  ulcer  char- 
acterized by  a  tendency  to  remain  open,  or  it  may  be  deep-seated  forming 
an  abscess  of  the  abdominal  wall  which  may  vary  in  depth,  occasionally  ex- 
tending down  to  the  peritoneum. 

Treatment. 

In  superficial  infections  simple  disinfection,  the  application  of  antisep- 
tic dressings,  and  keeping  the  surface  clean,  will  result  in  healing.  In  deep- 
seated  infections  it  is  important  to  curette  away  all  of  the  infected  tissue 
down  to  the  deepest  portion  of  the  infected  part,  to  disinfect  the  surface 
and  tampon  and  permit  healing  to  take  place  from  the  bottom.  In  either 
case  the  patient  should  be  kept  at  rest. 

Occasionally  such  an  infection  depends  upon  a  remnant  of  the  omphalo- 
mesenteric  duct  which  should  have  been  obliterated  before  the  birth  of  the 
child.  In  such  cases  the  mucous  membrane  lining  this  embryonic  structure 
must  be  entirely  removed  in  order  to  secure  a  permanent  cure,  because  any 
remnant  will  be  sure  to  be  the  cause  of  a  new  abscess  as  soon  as  the  tissues 
have  healed  over  this  area. 

In  many  of  these  the  duct  is  continuous  with  the  lumen  of  the  small  in- 
testine. Then  it  is  necessary  to  perform  an  abdominal  section,  excise  the 
entire  umbilicus,  determine  its  point  of  attachment  to  the  intestine  and  treat- 
this  attachment  precisely  after  the  manner  of  removing  the  appendix  from 
the  cecum,  especial  care  being  taken  not  to  narrow  the  lumen  of  the  small 
intestine  at  the  point  of  removal  of  this  remnant  of  the  duct. 


PART   VI. 

SURGERY   OF   THE    ESOPHAGUS   AND 
STOMACH. 

SURGERY  OF  THE  ESOPHAGUS. 

Surgery  of  the  esophagus  in  comparison  with  surgery  of  the  rest  of 
the  gastro-intestinal  tract  is  limited  and  probably  will  always  remain  so 
on  account  of  the  nature  and  position  of  the  part. 

In  many  conditions  the  treatment  is  of  a  palliative  character.  The  dis- 
tress from  interference  with  the  function  of  the  esophagus  is  so  great  that 
these  palliative  measures  seem  worth  while. 

Methods  of  Examination. 

The  most  common  method  is  the  passing  of  bougies.  In  sounding  the 
esophagus  it  is  important  to  remember  that  under  normal  conditions  the 
canal  possesses  four  constrictions.  It  is  also  important  to  know  the  total 
length  of  the  tract  and  the  distance  of  its  most  important  portion  from  the 
teeth.  The  esophagus  is  ten  inches  in  length.  It  begins  six  inches  from 
the  incisor  teeth  and  passes  through  the  diaphragm  sixteen  inches  from  the 
teeth.  It  is  crossed  by  the  arch  of  the  aorta  ten  inches  from  the  teeth. 

The  examination  with  a  bougie  should  be  conducted  very  carefully  and 
slowly,  for  in  this  way  only  is  it  possible  to  follow  the  course  of  the  tube 
without  injury,  especially  when  it  is  in  a  diseased  condition. 

Two  kinds  of  bougies  may  be  used  for  sounding  the  esophagus,  the 
English  bougies  or  the  olive-tipped  bougies.  The  former  are  constructed 
of  a  woven  material,  impregnated  with  a  gummy  material,  and  may  be 
softened  or  hardened  by  placing  them  in  warm  or  cold  water,  respectively. 
In  this  manner  they  may  be  bent  into  any  desired  shape.  The  olive-pointed 
bougies  consist  of  a  flexible  hard  rubber  staff,  on  the  point  of  which  is 
placed  an  olive-shaped  tip  of  hard  rubber  or  ivory. 

When  a  stricture  is  present  it  is  easier  to  determine  its  location  by 
means  of  the  olive-tipped  than  by  the  English  bougie. 

Before  sounding  an  esophagus,  artificial  teeth  should  be  removed  and 
the  patient  examined  for  aneurysm  of  the  aorta.  The  passing  of  bougies  in 
cases  of  aortic  aneurysm  has  been  known  to  cause  death  from  hemorrhage. 

Patients  who  are  being  examined  for  the  first  time  are  apt  to  gag, 
making  the  procedure  very  unpleasant.  This  may  be  overcome  to  a  great 
extent  by  first  spraying  the  pharynx  with  a  four  per  cent  solution  of  co- 
caine, allowing  the  patient  to  swallow  a  little  of  same,  then  waiting  five 
minutes  before  passing  the  sounds.  The  bougies  are  passed  with  the  pa- 
tient in  a  sitting  posture,  with  the  head  erect  or  bent  a  little  forward ;  then 
the  operator  places  the  index  finger  of  his  left  hand  on  the  base  of  the 


484  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

tongue,  pressing  downward  and  forward,  while  the  bougie  is  passed  by  the 
right  hand  along  the  posterior  wall  of  the  pharynx  to  the  beginning  of  the 
esophagus.  The  patient  is  now  told  to  swallow  and  the  sound  will  pass  on 
into  the  esophagus. 

A  half-inch  bougie  should  easily  pass  through  every  portion  of  the 
esophagus.  Its  failure  so  to  pass  is  a  sign  of  stricture.  A  three-fourths- 
inch  bougie  is  as  large  as  should  ever  be  used  in  dilating  a  stricture. 

Occasionally  in  passing  a  bougie  one  meets  with  an  apparent  obstruc- 
tion. In  these  cases  it  is  sufficient  under  normal  conditions  to  withdraw  the 
bougie  a  short  distance  and  then  advance  it  again,  or  the  obstruction  may 
be  overcome  by  asking  the  patient  to  swallow  or  to  bend  the  head  a  little 
forward. 

Esophagoscopy. 

Esophagoscopy  cannot  be  considered  an  important  aid  in  diagnosis. 
Little  is  to  be  determined  by  this  means  that  cannot  be  ascertained  by  the 
more  simple  methods  of  examination.  The  simplest  and  safest  form  of  esoph- 
agoscopy  is  by  the  straight  tube,  the  light  being  thrown  into  this  by  either 
a  Leiter  panelectroscope  or  a  Casper  electroscope.  Numerous  devices  for 
esophagoscopy  have  been  invented  during  the  past  few  years,  but  not  much 
evidence  of  value  has  accumulated  from  their  use.  Esophagoscopy  should 
only  be  attempted  by  those  who  have  had  special  training  along  this  line 
of  work. 

Radioscopy. 

Radioscopy  is  frequently  a  valuable  aid  in  the  diagnosis  of  esophageal 
lesions,  especially  in  the  location  of  foreign  bodies.  It  may  also  be  consid- 
ered in  connection  with  the  diagnosis  of  strictures,  dilatation  and  diverticula. 

A  rather  definite  outline  of  the  esophagus  may  be  obtained  by  an  X-ray 
photograph  by  administering  a  large  quantity  of  bismuth,  mixed  with  some 
starchy  food,  just  before  the  picture  is  taken. 

Percussion. 

Percussion  is  of  minor  importance  in  the  diagnosis  of  lesions  of  the 
esophagus.  In  case  of  diverticulum  in  the  neck,  if  the  latter  is  filled  with 
gas,  percussion  will  give  a  tympanitic  note ;  if  filled  with  food,  a  dull  note. 
Occasionally  in  the  presence  of  a  growth  in  the  esophagus  one  is  able  to 
determine  a  dull  area  corresponding  to  the  location  of  the  tumor. 

INFLAMMATORY  PROCESSES  OF  THE  ESOPHAGUS. 

Acute  catarrhal  inflammation  of  the  esophagus  may  result  from  the 
irritation  caused  by  foreign  bodies,  from  a  mild  scalding,  or  from  swallow- 
ing some  chemical  causing  an  irritation  but  not  strong  enough  to  cauterize. 
It  is  characterized  by  the  secretion  of  mucoid  material.  Where  the  inflam- 
mation is  more  severe,  it  may  result  in  superficial  erosion  or  ulcers,  but  these 
usually  heal  without  any  serious  consequences. 

Chronic  catarrhal  inflammation  of  the  esophagus  occurs  in  chronic  al- 
coholics, also  in  cases  of  stenosis  of  the  esophagus  from  various  causes,  and 
from  the  accumulation  of  food  in  a  dilated  portion  above  a  stricture.  These 
cases  usually  recover  without  any  complications  by  relieving  the  cause  of 
the  inflammation. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  485 

TOXIC  ESOPHAGITIS. 

Toxic  or  corrosive  esophagitis  occurs  after  the  ingestion  of  some 
chemic  caustic  substance,  or  a  scalding  fluid  may  act  in  the  same  manner. 
From  a  surgical  standpoint  toxic  esophagitis  is  the  most  important  inflam- 
mation of  the  esophagus,  because  of  the  complications  which  are  apt  to  fol- 
low, especially  the  formation  of  strictures.  In  cases  where  the  injury  is 
only  superficial,  the  epithelial  layer  may  be  thrown  off  without  any  com- 
plications following.  Where  the  erosion  is  deep,  causing  a  slough  of  the 
entire  thickness  of  the  mucosa,  and  perhaps  some  of  the  muscular  coat,  the 
inflammation  may  extend  beyond  the  esophagus,  forming  a  peri-esophageal 
abscess  extending  into  the  mediastinum.  The  eroded  area  undergoes  cicat- 
rization after  the  slough  is  thrown  off  and  as  a  result  of  the  contraction  of 
this  scar  a  stricture  is  apt  to  follow.  Swallowing  of  a  large  amount  of  the 
concentrated  alkalies  or  acids  is  apt  to  end  fatally  on  account  of  the  slough 
it  usually  causes  in  the  stomach. 

The  authors  recently  had  a  case  of  a  woman  who  tried  to  commit  suicide 
by  swallowing  one  ounce  of  strong  hydrochloric  acid.  The  patient  was  re- 
markably free  from  esophageal  symptoms,  but  nine  days  after  the  ingestion 
of  the  acid  she  vomited  a  large  roll  of  tissue,  which  proved  to  be  a  consid- 
erable portion  of  the  mucous  lining  of  the  stomach.  The  tissue  was  in  one 
piece,  was  somewhat  gangrenous  in  appearance  and  measured  fifty  square 
inches.  The  patient  was  kept  on  liquid  food  and  had  no  symptom  referable 
to  the  esophagus,  but  complained  some  of  a  burning  pain  in  the  stomach. 
After  about  four  weeks  she  began  to  lose  in  weight  rapidly  and  every  second 
or  third  day  would  vomit  a  large  amount  of  dark  fluid.  We  first  saw  the 
patient  twelve  weeks  after  the  swallowing  of  the  acid.  At  this  time  she 
complained  of  a  large  swelling  in  the  abdomen,  which  she  said  seemed  like 
a  large  sac  of  water.  The  patient  was  greatly  emaciated  and  on  exami- 
nation there  was  a  soft  mass  extending  from  the  epigastrium  to  the  sym- 
physis  pubis.  A  distinct  splashing  sound  could  be  elicited  and  a  peristaltic 
wave  seen  beginning  in  the  left  inguinal  region  and  extending  to  the  region 
of  the  pylorus.  A  stomach  tube  was  inserted  which  passed  easily,  and  five 
quarts  of  a  dark-brownish  fluid  was  withdrawn.  The  patient  was  placed 
on  rectal  feeding  and  gastric  lavage  was  used  three  times  daily  for  three 
days.  At  this  time  a  laparotomy  was  performed.  The  stomach  had  con- 
tracted to  the  level  of  the  umbilicus  and  there  was  a  cicatricial  mass  in  the 
pyloric  end,  causing  practically  a  complete  obstruction  of  the  pylorus.  A 
gastro-enterostomy  was  performed.  The  patient  did  very  well  for  nine 
days,  when  she  died  suddenly  from  pulmonary  embolism.  Examination  of 
the  esophagus  at  the  post  mortem  showed  no  evidence  of  injury  from  the 
swallowing  of  the  acid. 

Treatment. 

The  treatment  of  corrosive  esophagitis  is  principally  symptomatic  at 
first.  Rectal  feeding,  ice,  narcotics.  Examination  with  bougies  should  not 
be  undertaken  as  long  as  there  is  any  evidence  of  recent  ulceration.  Such 
ulcerations  usually  continue  from  two  to  four  weeks,  according  to  the  de- 
gree of  the  burn.  After  four  weeks  bougies  may  be  passed  as  a  prophylac- 
tic measure  against  the  formation  of  strictures. 


486  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

PHLEGMON  OF  THE  ESOPHAGUS. 

Phlegmonous  inflammation  of  the  esophagus  is  of  rare  occurrence. 
This  purulent  inflammation  may  occur  after  penetrating  injuries,  and  in- 
juries caused  by  caustics  or  from  extension  from  abscess  of  the  stomach, 
and  by  rupture  of  a  peri-esophageal  abscess.  The  inflammation  may  be  cir- 
cumscribed or  diffuse,  extending  over  large  areas.  Abscesses  may  form 
with  bulging  of  the  mucous  membrane  of  the  esophagus,  causing  an  ob- 
struction. These  abscesses  usually  rupture  spontaneously  into  the  esoph- 
agus. The  symptoms  in  these  cases  vary ;  fever,  chills,  difficulty  in  swallow- 
ing, pain  along  the  course  of  the  esophagus,  especially  behind  the  sternum. 
There  may  be  coughing  and  regurgitation  of  pus  if  there  is  abscess  for- 
mation. The  treatment  is  ordinarily  symptomatic,  but  some  authors  sug- 
gest esophagoscopy  and  incision  in  case  of  abscess  formation. 

ULCER  OF  THE  ESOPHAGUS. 

Various  forms  of  ulceration  are  met  with  in  the  esophagus :  gangren- 
ous ulcers  from  pressure,  syphilitic,  tubercular  and  the  peptic  or  round  ul- 
cers. Gangrenous  ulcers  may  be  caused  by  pressure  from  within  or  from 
without.  Goitre  or  some  other  tumor  may  make  pressure  upon  the  cricoid 
or  one  of  the  tracheal  rings,  causing  pressure  on  the  esophagus,  resulting 
in  a  necrosis  of  one  or  both  of  the  walls.  Aneurysm  of  the  aorta  may  act 
in  the  same  manner,  also  foreign  bodies  from  within. 

Syphilitic  ulcers  may  occur  in  the  esophagus,  but  are  very  rare.  They 
usually  are  situated  in  the  upper  portion  of  the  tube.  The  lesion  is  usually 
a  gumma,  and  frequently  results  in  scar  formation,  causing  constriction.  In 
many  cases  the  diagnosis  is  made  by  noticing  the  effect  of  anti-syphilitic 
treatment. 

The  occurrence  of  tuberculous  ulcers  has  recently  been  positively  de- 
termined, but  they  are  very  rare. 

Peptic  or  round  ulcers,  analogous  to  those  found  in  the  stomach,  occa- 
sionally are  found  in  the  esophagus.  They  are  frequently  associated  with 
ulcers  of  the  stomach  and  are  situated  in  the  lower  portion  of  the  esoph- 
agus. They  may  or  may  not  cause  symptoms,  but  when  present  they  are 
similar  to  those  of  gastric  ulcer. 

NEW  GROWTHS  OF  THE  ESOPHAGUS. 

Carcinoma  is  the  most  frequent  of  the  new  growths  of  the  esophagus, 
in  fact  it  is  the  most  common  disease  met  with  in  the  esophagus.  It  may 
occur  either  primary  or  secondary.  When  secondary  it  usually  occurs  by 
direct  extension  from  neighboring  organs.  It  may  occur  through  inocu- 
lation from  the  secretion  of  a  carcinomatous  ulcer  higher  up  in  the  gastro- 
intestinal tract. 

Carcinoma  of  the  esophagus  is  most  common  in  the  male  and,  the  same 
as  other  carcinomas,  is  usually  a  disease  of  advanced  life. 

It  is  usually  situated  at  one  of  the  normal  constrictions  of  the  esopha- 
gus corresponding  to  the  cricoid  cartilage,  the  bifurcation  of  the  trachea 
and  the  hiatus  of  the  esophagus.  This  fact  rather  favors  the  view  that 
there  may  be  some  connection  between  repeated  irritations  and  the  devel- 
opment of  carcinoma,  as  these  portions  of  the  esophagus  are  constantly  sub- 
jected to  irritation  more  than  the  rest  of  the  canal. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  487 

Strictures  are  also  most  common  at  these  points,  so  it  is  possible  that 
carcinoma  develops  in  a  cicatricial  stricture  or  some  other  scar. 

It  is  estimated  that  about  fifty  per  cent  of  the  cases  of  esophageal  car- 
cinoma occur  at  the  cardia,  or  just  above  where  the  esophagus  passes  through 
the  diaphragm.  About  forty  per  cent  are  found  near  the  bifurcation  of  the 
trachea,  and  less  than  ten  per  cent  in  the  cervical  portion  of  the  esophagus. 

Symptoms. 

The  most  important  and  usually  the  earliest  symptom  of  carcinoma  of 
the  esophagus  is  dysphagia.  The  manifestations  are  those  of  a  slowly-ad- 
vancing stenosis.  The  patient  usually  comes  giving  a  history  of  having  been 
in  good  health  until  a  few  months  ago,  when  he  began  to  have  some  diffi- 
culty in  swallowing  meat  or  other  coarse  food.  This  condition  gradually 
becomes  worse,  when  the  patient  has  difficulty  in  swallowing  soft  foods, 
and  finally  confines  himself  solely  to  liquid  food.  Usually  by  the  time  the 
patient  consults  a  surgeon  he  has  lived  on  liquids  for  a  considerable  period 
on  account  of  the  difficulty  of  swallowing  solids.  Hand  in  hand  with  the 
difficulty  of  swallowing,  there  is  usually  a  sense  of  weakness  and  a  pro- 
gressive loss  of  weight. 

Considerable  improvement  may  be  noted  upon  the  administration  of 
non-irritating  liquid  foods.  A  gain  of  several  pounds  is  possible  for  a 
short  time  by  giving  an  abundance  of  milk,  cream  and  raw  eggs.  There  is 
seldom  any  vomiting,  but  usually  a  regurgitation  of  food  and  large  quanti- 
ties of  mucus.  This  regurgitation  may  take  place  very  quietly  and  is  en- 
tirely different  from  vomiting.  In  the  later  stages  the  accumulation  of 
thick,  tenacious  mucus  above  the  stenosis  may  cause  gagging  and  retching, 
which  is  very  annoying. 

It  is  not  uncommon  to  have  some  hoarseness  rather  early,  gradually 
becoming  more  pronounced  on  account  of  the  further  involvement  of  the 
recurrent  laryngeal  nerve. 

As  a  rule  there  is  more  or  less  pain  associated  with  carcinoma  of  the 
esophagus.  This  is  described  as  a  sense  of  burning  or  pressure  in  the 
throat  or  chest,  especially  during  swallowing.  Occasionally  the  pain  pre- 
cedes the  dysphagia.  It  is  frequently  felt  in  the  back,  radiating  to  the 
shoulders  and  the  back  of  the  neck.  The  loss  of  weight  and  strength  in 
these  cases  is  at  first  due  to  the  dysphagia,  and  later  they  result  also  from 
the  malignant  pathological  process.  In  advanced  instances  it  is  not  uncom- 
mon to  have  a  contracted  pupil  on  one  side.  According  to  Hitzig  this  is 
found  in  about  one-sixth  of  the  cases.  The  left  pupil  is  most  frequently  in- 
volved. It  is  due  to  pressure  upon  the  sympathetic  nerve. 

While  an  involvement  of  the  recurrent  nerves  may  occasionally  be 
found  as  an  early  symptom,  it  most  often  means  that  the  disease  has  made 
considerable  progress.  The  pressure  may  be  due  to  the  growth  itself,  but 
is  probably  most  often  due  to  an  involvement  of  the  lymphatic  glands. 

Besides  hoarseness,  this  pressure  may  cause  attacks  of  dyspnea. 

Diagnosis. 

By  taking  a  careful  history  one  can  usually  obtain  many  important  di- 
agnostic points. 

In  a  patient  with  slowly-progressing  stenosis,  and  the  absence  of  any 
traumatic,  specific  or  other  etiological  factor,  the  obstruction  is  more  apt  to 
be  due  to  new  growth  than  to  a  cicatricial  stenosis.  Then  if  the  patient  be 
past  forty  years  of  age,  is  a  male  and  the  above-mentioned  symptoms  are 


488  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

present,  with  emaciation  and  cachexia,  the  diagnosis  of  carcinoma  is  fairly 
certain. 

On  palpation  there  is  occasionally  a  tumor  or  induration  felt  in  the 
neck.  This  may  be  the  primary  growth,  but  most  often  it  is  metastases  of 
the  lymphatic  glands.  Examination  with  bougies  may  further  aid  in  the 
diagnosis  by  determining  the  existence  of  an  obstruction  and  its  location. 
This  examination  may  prove  negative,  even  though  a  carcinoma  be  present. 
The  growth  may  be  so  small  that  the  bougie  may  glide  past  without  offer- 
ing a  definite  resistance.  A  negative  examination  may  also  be  due  to  the 
fact  that  necrosis  has  taken  place,  and  the  position  of  the  growth  projecting 
into  the  lumen  of  the  esophagus  may  grow  only  in  the  long  axis  of  the 
tube,  so  that  it  causes  no  marked  obstruction.  When  ulceration  has  taken 
place  more  can  often  be  determined  by  pass  ng  a  stomach  tube  or  hollow 
bougie,  as  particles  of  tissue  may  become  Caught  in  the  fenestrum  of  the 
tube  and  the  diagnosis  positively  determined  by  the  examination  of  such 
fragments. 

It  is  often  difficult  to  differentiate  between  carcinoma  of  the  esophagus 
and  aneurysm  of  the  aorta. 

If  one  will  bear  in  mind  the  arn.ngement  of  the  lymphatic  glands  of 
the  mediastinum,  he  can  readily  perceive  how  two  conditions  so  diverse  as 
an  aneurysm  of  the  aorta  and  carcinoma  of  the  esophagus  may  cause  almost 
identical  symptoms. 

The  lymphatic  glands  are  in  actual  contact  with  the  esophagus,  so  that 
often  secondary  involvement  occurs  very  early.  This  being  the  case,  we 
have  a  tumor  growth  in  the  mediastinum  which  may  cause  the  ordinary 
signs  and  symptoms  caused  by  an  aneurysm  in  the  same  location.  The 
glands  may  enlarge  so  much  more  rapidly  than  the  primary  tumor  that  there 
may  be  symptoms  of  intra-thoracic  pressure  before  there  are  any  signs  of 
obstruction  of  the  esophagus.  In  such  a  case  as  this,  the  symptoms  would 
naturally  be  the  same  in  both  conditions,  being  due  to  pressure  on  the  same 
structures. 

Dyspena,  which  is  a  fairly  constant  sign  in  case  of  aneurysm  of  the 
aorta,  is  also  almost  as  constant  a  sign  in  carcinoma  of  the  esophagus.  In 
both  the  aneurysm  and  the  mediastinal  metastasis  from  the  esophageal  can- 
cer the  dyspnea  is  due  to  pressure  on  the  bronchi  or  trachea.  Dysphagia 
very  naturally  causes  the  surgeon  to  think  that  he  is  dealing  with  a  growth 
of  the  esophagus,  but  in  many  cases  of  aneurysm  of  the  aorta  the  esoph- 
agus is  affected  sufficiently  to  cause  dysphagia.  Even  though  the  aneurysm 
does  not  press  directly  on  the  esophagus,  it  may  cause  dysphagia  by  pressure 
on  the  vagus,  or  its  esophageal  branches. 

Thus  we  see  that  it  is  often  difficult  to  differentiate  between  carcinoma 
of  the  esophagus  and  aneurysm  of  the  aorta,  when  the  growth  is  situated 
in  the  thoracic  portion  of  the  esophagus,  especially  if  there  is  an  early  in- 
volvement of  the  mediastinal  glands. 

Prognosis. 

The  prognosis  of  carcinoma  of  the  esophagus  is  always  unfavorable. 
So  far  as  known  no  permanent  cures  have  been  effected  even  after  resec- 
tion. The  average  duration  of  the  disease  is  from  six  months  to  two  years. 
The  majority  of  the  cases  usually  succumb  one  year  after  the  manifestations 
of  the  disease. 

Death   usually   takes   place   slowly    from    inanition    and   carcinomatous 


PLATE  LXV. 

ELASTIC  DILATING  BOUGIE  ESPECIALLY  DESIGNED  FOR  ESOPHAGEAL  STRICTURE. 

1,  Graduated  flexible  bougie  hollow,  made  of  spiral  steel;  2,  Lead  rod  to  be  placed 
in  lumen  of  1  enabling  the  operator  to  give  the  bougie  definite  curves.  3,  Short,  4 
long,  filiform  bougie  to  be  screwed  into  the  distal  end  of  1. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  4QI 

cachexia,  or  there  may  be  the  typical  picture  of  pyemia.  Where  there  is  a 
perforation  and  rupture  into  the  air  passages,  death  takes  place  from  pneu- 
monia or  gangrene  of  the  lung.  Occasionally  these  patients  meet  with  a 
rapid  and  sudden  death  from  erosion  and  rupture  into  the  large  blood  ves- 
sels. 

Treatment. 

The  treatment  comprises  the  following  non-operative  procedures,  viz., 
dilatation  with  bougies  and  dilation  by  permanent  tubage.  The  operative 
methods  are  resection  of  the  esophagus ;  esophagostomy  and  gastrostomy. 

Dilatation. 

Dilatation  with  bougies  is  quite  generally  employed,  especially  by  the 
general  practitioner.  This  is  usually  successful  for  a  time,  as  the  soft  car- 
cinomatous  tissue  yields  readily.  This  form  of  treatment  is  often  unavoid- 
able as  the  patient  will  not  consent  to  the  operative  procedures.  It  should 
be  borne  in  mind  that  the  bougies  cause  mechanical  irritation,  and  that  the 
growth  may  be  excited  by  their  use.  Great  care  should  be  exercised  in 
the  use  of  the  bougies  on  account  of  danger  of  perforating  into  the  neigh- 
boring organs  during  the  procedure. 

The  conical-shaped  English  bougies  are  the  best  for  this  purpose,  as 
they  are  soft  and  pliable.  The  bougies  are  introduced  as  described  above. 
Occasionally  the  carcinomatous  stricture  will  be  so  small  that  it  will  be 
impossible  to  pass  the  bougie  through  it.  Then  a  filiform  bougie  may  be 
passed,  to  the  end  of  which  is  attached  a  conical  spiral  bougie  shown  in 
Plate  LXV.  When  this  is  withdrawn  a  small-sized  English  bougie  is  passed, 
followed  by  the  larger  sizes.  Some  temporary  relief  is  afforded  in  this 
manner. 

Permanent  dilation  by  introducing  a  hard  rubber  tube  into  the  stricture 
is  seldom  used.  Unpleasant  accidents  may  occur,  such  as  breaking  or  swal- 
lowing the  string,  and  the  constant  presence  of  the  string  in  the  mouth  is 
very  annoying  to  the  patient. 

Operative  Procedures. 

Resection  of  the  Esophagus. — The  majority  of  cases  of  carcinoma  of 
the  esophagus  are  not  accessible  to  radical  treatment.  The  authors  have 
had  no  personal  experience  in  resection  of  the  esophagus  for  carcinoma.  In 
the  few  cases  recorded  in  the  literature  of  the  subject  the  immediate  mor- 
tality is  high  and  the  relief  in  the  other  cases  was  only  transitory. 

It  is  quite  probable  that  with  further  development  of  Sauerbruck's 
method  of  operating  within  a  pneumatic  cabinet  under  negative  pressure,  a 
satisfactory  operation  for  resection  of  the  esophagus  in  cases  of  carcinoma 
may  be  made  possible. 

Esophagostomy. 

Esophagostomy  is  occasionally  performed  and  the  patient  fed  through 
this  fistulous  opening.  This  operation  is  applicable  only  in  cases  of  carci- 
noma situated  high  up  in  the  cervical  portion  where  the  opening  can  be 
made  below  the  stricture.  It  is  doubtful  whether  feeding  through  on  esoph- 
ageal  fistula  is  less  annoying  to  the  patient  than  through  a  gastrostomy 
opening ;  the  detail  of  the  latter  proceeding  being  much  easier  for  the  pa- 
tient to  carry  out  himself.  As  a  rule  a  gastrostomy  is  preferable  to  an 
esophagostomy  as  a  means  of  these  patients  taking  nourishment. 


492  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

The  technique  of  esophagostomy  is  described  under  the  subject  of  for- 
eign bodies  in  the  esophagus. 

Gastrostomy. 

Gastrostomy  is  indicated  where  the  patient  cannot  take  enough  food  by 
mouth,  as  is  shown  by  rapid  emaciation.  The  earlier  the  operation  is  per- 
formed, the  more  satisfactory  will  be  the  result.  If  a  positive  diagnosis  of 
carcinoma  is  made,  a  gastrostomy  should  be  done,  even  though  the  patient 
can  still  swallow  liquids.  Of  course  a  gastrostomy  cannot  stop  the  prog- 
ress of  the  disease,  but  it  may  inhibit  ichorous  decomposition,  which  is 
caused  by  food  remaining  in  the  ulcerated  area.  As  a  result  of  the  opera- 
tion the  carcinoma  may  grow  less  rapidly,  because  the  continuous  irritation 
from  the  passage  of  food  has  been  relieved.  Oftentimes  both  physicians 
and  surgeons  decide  upon  an  operation  too  late.  This  accounts  for  the  fact 
that  the  mortality  is  rather  high  in  this  operation.  If  gastrostomy  is  per- 
formed at  the  proper  time,  the  life  of  the  patient  may  be  prolonged  for  sev- 
eral months,  or  even  more  than  a  year. 

In  choosing  the  operation  it  is  necessary  to  select  a  method  which  may 
be  rapidly  carried  out  and  at  the  same  time  effect  a  closure  of  the  fistula. 

Preparatory  Treatment. 

If  the  obstruction  is  complete  the  operation  should  be  done  at  once 
after  securing  an  evacuation  of  the  bowels  by  means  of  a  large  enema.  So 
long  as  there  is  still  a  slight  passage  in  the  obstruction  it  is  well  to  admin- 
ister some  saline  mineral  water  freely  every  morning  for  several  days,  in 
order  to  secure  a  free  evacuation  of  the  bowels,  because  one  frequently 
finds  large  accumulations  in  the  colon  in  these  cases,  as  they  have  usually 
been  constipated  for  a  long  time,  and  they  will  bear  an  operation  much 
better  if  there  is  no  decomposing  substance  in  any  part  of  the  intestinal 
canal. 

If  the  patient  is  very  weak  it  is  frequently  possible  to  increase  his 
strength  considerably  by  giving  some  of  the  various  concentrated  pre- 
digested  foods  in  considerable  quantities  at  regular  intervals  of  two  or 
three  hours  for  a  few  days.  Ordinarily,  however,  they  bear  the  operation 
well  if  performed  rapidly  and  with  a  minimum  amount  of  traumatism,  so 
that  it  is  only  necessary  to  give  the  above  preparatory  treatment  to  patients 
who  have  had  little  or  no  care  previous  to  their  admission  to  the  hospital. 

The  field  of  operation  is  prepared  as  in  every  abdominal  operation. 

Technique. 

The  incision  is  made  through  the  outer  edge  of  the  left  rectus  ab- 
dominis  muscle  from  one-half  to  three  inches  in  length.  The  length  of  the 
incision  will  depend  upon  the  extent  of  the  contraction  of  the  stomach  and 
the  thickness  of  the  stomach  wall.  In  case  of  a  contracted  stomach  with 
a  thick  wall,  it  is  necessary  to  make  the  incision  longer  than  where  there 
is  a  large,  thin-walled  stomach,  so  as  to  secure  a  sufficient  amount  of  space 
to  conduct  the  necessary  manipulations  without  causing  too  much  traumat- 
ism. As  soon  as  the  abdomen  has  been  opened  a  portion  of  the  anterior 
wall  of  the  stomach  is  drawn  into  the  wound  and  two  purse-string  stitches 
of  fine  silk  or  linen  are  applied,  as  shown  in  Plate  LXVI ;  the  circle  de- 
scribed by  the  first  stitch  being  about  three-fourths  of  an  inch  in  diameter. 
In  each  case  a  little  more  than  a  full  circle  is  described,  in  order  to  provide 
against  a  possible  defect.  These  stitches  grasp  all  of  the  layers  of  the 


PLATE  LXVI. 
GASTROSTOMV. 

Represents   the    stomach    wall    drawn  out   through   the   abdominal    incision,    with 
two  circular  purse-string  sutures  in  position. 


PLATE  LXVII. 

GASTROSTOMY. 

The  same  as  Plate  LXVI,  with  retention  catheter  introduced  through  an  opening 
which  has  been  made  in  the  center  of  the  circle  formed  by  the  purse-string  sutures. 
The  portion  contained  within  this  circle  has  been  inverted  into  the  cavity  of  the  stom- 
ach and  the  sutures  have  been  tied  and  cut  short. 


PLATE  LXVIII. 

GASTUOSTOM  v. 

Lemhert  sutures  applied  to  either  side  of  the  cntheter  in  order  to  invert  the  wall 
of  the  stomach  still  further,  in  order  to  prevent   leakage  along  the  retention  catheter. 


PLATE  LXIX. 

GASTROSTOMY. 

Represents  the  manner  of  attaching  the  stomach  to  the  abdominal  wall  by  means 
of  cat-gut  sutures,  uniting  the  stomach  to  the  parietal  peritoneum  and  transversalis 
fascia.  Two  deep  silkworm  gut  sutures,  which  extend  through  the  entire  abdominal 
wall,  grasp  the  wall  of  the  stomach  in  order  to  act  as  stay  sutures. 


PLATE  LXX. 
GASTROSTOMY. 

The  same  as  Plate  LXIX  with  the  addition  of  a  piece  of  iodoform  gauze  folded 
about  the  retention  catheter  and  attached  to  the  wall  of  the  stomach  by  interrupted 
cat-gut  sutures,  in  order  to  make  the  adhesion  to  the  abdominal  wall  more  secure. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  503 

stomach  down  to  the  mucous  membrane,  including  the  submucous  connect- 
ive tissue.  The  space  within  the  inner  circle  is  now  punctured  with  a  trocar, 
and  a  tube  from  one-quarter  to  one-half  an  inch  in  diameter  made  out  of 
rather  stiff,  pure  rubber,  fashioned  after  the  pattern  of  a  Jacob's  retention 
catheter,  is  inserted  into  this  opening.  This  will  produce  an  infolding  of 
the  stomach  wall,  as  shown  in  Plate  LXVII,  which  is  still  further  exag- 
gerated when  the  purse-string  sutures  are  tied. 

The  enlargement  at  the  end  of  the  tube  prevents  its  slipping  out  of 
the  opening,  and  the  close  application  of  the  serovis  surface  to  the  tube  pre- 
vents any  leakage.  This  conditign  is  still  further  enforced  by  the  applica- 
tion of  several  rows  of  Lembert  sutures  to  each  side  of  the  tube,  as  shown 
in  Plate  LXVIII. 

In  a  thin- walled  stomach  it  may  be  desirable  to  apply  four  or  five  rows 
of  these  interrupted  sutures,  while  in  a  thick-walled  stomach  two  or  three 
rows  outside  of  the  purse-string  sutures  will  suffice.  The  end  of  the  tube 
in  the  stomach  should  be  closed  with  a  cork  or  clamped  with  a  convenient 
contrivance,  so  that  no  stomach  contents  may  be  expelled  during  the  course 
of  the  operation.  The  important  condition  to  be  obtained  is  a  provision 
against  leakage,  which  the  above-described  method  has  always  accomplished 
in  a  most  satisfactory  manner. 

The  next  step  is  the  attachment  of  the  stomach  to  the  abdominal  wall. 
This  is  accomplished  by  first  inserting  silk-worm  gut  sutures  through  all 
the  layers  of  the  abdominal  wall,  then  all  the  layers  of  the  stomach  wall 
down  to  the  mucous  membrane,  then  out  through  all  of  the  layers  of  the 
abdominal  wall  on  the  opposite  side,  as  shown  in  Plate  LXIX.  Then  the 
stomach  wall  is  sutured  to  the  peritoneum  and  transversalis  fascia  by  a  num- 
ber of  interrupted  sutures.  The  abdominal  wound  is  then  closed  in  the 
usual  manner  by  suturing  each  layer  separately,  the  feeding  tube  being  per- 
mitted to  pass  out  through  the  middle  of  the  wound.  A  dry  sterile  gauze 
dressing  is  applied,  the  tube  being  permitted  to  pass  out  through  the  center 
of  the  dressing  and  the  binder  holding  the  dressing  in  place,  so  that  the 
patient  may  be  fed  without  disturbing  the  dressing. 

In  some  of  these  patients  who  have  become  much  reduced  in  strength, 
the  adhesions  formed  between  the  stomach  and  the  abdominal  wall  are  very 
frail  unless  increased  by  means  of  some  irritation.  For  this  purpose  the 
use  of  iodoform  gauze  has  proven  very  satisfactory,  it  being  applied  in  the 
following  manner :  A  piece  of  iodoform  gauze  is  folded  around  the  feed- 
ing tube,  as  shown  in  Plate  LXX,  and  stitched  to  the  stomach  by  a  num- 
ber of  interrupted  catgut  sutures.  All  of  the  other  steps  of  the  operation 
are  carried  out  as  above,  this  simply  being  an  additional  safeguard.  After 
about  ten  days  the  catgut  sutures  will  be  absorbed  and  the  gauze  may  be 
withdrawn.  It  will  usually  be  found  quite  adherent  and  the  adhesions  be- 
tween the  stomach  and  the  abdominal  wall  will  have  become  exceedingly 
firm  by  this  time. 

After-Treatment. 

If  the  obstruction  has  been  complete  or  nearly  so,  and  the  patient  suf- 
fered severely  from  thirst  before  the  operation,  half  a  pint  of  warm  normal 
salt  solution  should  be  poured  into  the  stomach  through  the  feeding  tube  at 
the  close  of  the  operation,  and  this  should  be  repeated  every  half  hour  until 
the  patient  is  satisfied.  If  he  had  been  able  to  swallow  before  the  opera- 
tion, he  may  be  allowed  to  drink  water  naturally  after  the  procedure  if 


504  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

this  causes  no  distress  or  annoyance;  otherwise  it  is  to  be  given  through 
the  feeding  tube  entirely.  After  a  time  the  absence  of  irritation  may  cause 
a  disappearance  of  the  complete  obstruction  and  then  the  patient  will  again 
be  able  to  take  liquids  by  mouth.  In  the  meantime  he  should  be  fed  regu- 
larly every  three  hours  with  peptonized  milk,  raw  egg,  the  juice  extracted 
from  roast  beef  or  broiled  steak,  rich  broths,  soups  and  mush.  The  food 
may  be  poured  into  the  stomach  through  a  funnel,  or  an  ordinary  glass 
syringe  may  be  attached  to  the  feeding  tube  and  this  will  serve  as  a  funnel. 

Later  the  patient  may  chew  any  kind  of  food  very  fine,  and  thus  mix 
it  with  saliva.  He  can  then  inject  this  through  the  feeding  tube  into  the 
stomach.  These  patients  can  thus  improve  their  digestion,  especially  of 
starchy  food,  and  may  continue  enjoying  their  meals  in  this  way. 

Almost  invariably  these  patients  gain  rapidly  in  weight  and  strength, 
because  the  enforced  rest  of  the  stomach  and  intestines  has  usually  placed 
these  organs  in  a  condition  in  which  they  can  thoroughly  digest  an  abun- 
dance of  food.  We  have  repeatedly  observed  these  sufferers  gain  sufficient- 
ly in  strength  in  a  few  weeks  to  enable  them  to  do  hard  labor,  which  was 
continued  until  the  carcinoma  had  implicated  some  other  important  organ, 
either  by  invasion  or  by  the  formation  of  metastasis. 

It  is,  of  course,  necessary  to  explain  to  the  friends  of  the  patient  that 
this  operation  cannot  result  in  a  cure  of  the  disease,  but  that  it  can  simply 
give  temporary  relief.  This  relief,  however,  is  so  great,  and  the  risk  in  ob- 
taining it  is  so  slight,  that  it  is  an  operation  which  may  be  very  strongly  rec- 
ommended. Aside  from  the  distress  due  to  hunger,  and  especially  to  thirst, 
patients  afflicted  with  obstruction  of  the  esophagus  suffer  pain  but  slightly, 
consequently  the  relief  given  by  this  operation  is  relatively  very  complete. 

CYSTS,  PAPILLOMATA,  MYOMATA  AND  SARCOMATA  OF  THE 

ESOPHAGUS. 

Many  of  the  growths  occurring  in  the  esophagus,  such  as  warts,  cysts, 
papillomata,  fibromata,  lipomata.  possess  only  a  pathological  interest,  as 
they  rarely  cause  disturbance. 

Klebs  has  pointed  out  the  analogy  between  diseases  of  the  esophagus 
and  those  of  the  skin.  Thus  in  the  esophagus  are  found  warts  which  are 
usually  small  and  spread  over  different  portions  of  the  tract.  It  would  seem 
probable  that  these  warts  might  develop  into  carcinoma  as  is  seen  in  skin 
warts,  but  so  far  such  an  event  has  never  been  demonstrated. 

Retention  cysts  of  the  mucous  glands  have  also  been  described.  On 
account  of  their  small  size  they  usually  do  not  cause  any  symptoms. 

Fibromata  and  lipomata  also  occur,  but  are  very  rare.  They  are  usually 
autopsy  findings,  as  they  run  their  course  without  producing  symptoms. 

Sarcomata  of  the  esophagus  are  rather  rare  and  the  symptoms  and 
course  of  the  disease  are  similar  to  those  of  carcinoma.  A  positive  diag- 
nosis can  only  be  made  by  securing  a  portion  of  the  tissue  for  microscop- 
ical examination.  The  treatment  is  the  same  as  described  for  carcinoma. 

Pedunculated  tumors  of  the  esophagus  are  classified  as  polypi.  They 
are  rather  rare.  They  are  usually  attached  to  the  upper  end  of  the  esoph- 
agus in  the  region  of  the  cricoid  cartilage.  Small  polypi  cause  no  symp- 
toms. The  larger  ones  may  cause  difficulty  in  swallowing  and  occasionally 
the  distal  end  of  the  polypus  is  thrown  upwards  into  the  throat,  causing 
chokiner  and  difficult v  in  breathing. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  505 

INJURIES    OF   THE   ESOPHAGUS. 

Trauma  from  an  Internal  Source. 

The  injuries  of  the  esophagus  produced  by  violence  from  within  are 
those  resulting  from  swallowing  various  corrosive  drugs,  from  foreign 
bodies  that  have  been  swallowed,  also  by  passing  bougies,  coin-catchers  and 
other  instruments.  Injuries  from  the  passing  of  instruments  are  particularly 
liable  to  occur  in  the  presence  of  pathological  changes  such  as  carcinoma, 
ulcer,  stricture,  etc.  Perforation  of  the  esophagus  is  a  serious  condition, 
as  it  may  result  in  a  fatal  mediastinitis  or  pleuritis. 

EXTERNAL  INJURIES  OF  THE  ESOPHAGUS. 

The  esophagus  being  so  deeply  situated  injuries  from  violence  from 
without  are  extremely  rare.  \Younds  of  the  cervical  portion  are  the  most 
common  and  usually  occur  as  a  result  of  attempted  suicide. 

These  wounds  are  usually  high  up  on  the  neck  in  the  region  of  the 
larynx  or  hyoid  bone,  so  that  the  wound  of  the  alimentary  canal  is  either 
high  up  in  the  esophagus  or  in  the  pharynx.  In  these  cases  the  respiratory 
passages  are  practically  always  injured  at  the  same  time. 

Injury  of  the  esophagus  alone  in  the  thoracic  portion  is  extremely  rare. 
This  may  result  from  daggers,  bayonets  or  bullets.  Injuries  of  adjacent 
organs,  as  heart,  lungs,  large  vessels,  etc.,  which  are  usually  fatal  in  them- 
selves on  account  of  their  character  and  anatomical  position,  are  apt  to  oc- 
cur at  the  same  time.  The  danger  from  injury  to  the  esophagus  is  in  itself 
very  dangerous  on  account  of  the  escape  of  food  into  the  surrounding  tis- 
sues, resulting  in  ichorous  abscesses,  mediastinitis  or  pleuritis. 

Treatment. 

\Yhen  the  injury  is  in  the  cervical  portion,  the  first  thing  is  to  control 
the  hemorrhage  and  to  avoid  asphyxia.  It  frequently  is  necessary  to  per- 
form a  tracheotomy.  If  the  condition  is  such  as  to  warrant  an  operation 
an  attempt  should  be  made  to  suture  the  esophagus,  also  the  trachea  if  that 
has  been  severed.  The  best  method  is  that  employed  in  suturing  the  in- 
testines, first  suturing  the  mucous  membrane  and  then  the  muscular  coat 
over  this. 

Should  the  injury  be  in  the  thoracic  portion  the  treatment  is  practically 
hopeless,  being  usually  limited  to  feeding  the  patient  per  rectum  or  through 
a  stomach  tube,  if  this  can  lie  passed  down  through  the  injured  portion.  If 
the  patient  is  able  to  stand  an  operation  a  gastrostomy  will  be  the  best 
method  of  feeding. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS. 

The  lodgment  of  foreign  bodies  in  the  esophagus  is  not  an  uncom- 
mon condition  and  is  classed  as  one  of  the  emergencies  in  the  practice  of 
surgery,  as  they  frequently  require  prompt  action  on  the  part  of  the  sur- 
geon. The  accident  is  most  often  seen  in  the  very  young  and  the  insane. 
The  foreign  bodies  most  often  found  are  coins,  buttons,  pins,  keys,  glass 
beads,  bones  and  various  kinds  of  small  toys.  Foreign  bodies  are  frequent- 
ly found  in  food,  such  as  fish  bones,  fruit  stones,  pieces  of  glass  and  enamel. 
In  adults  the  most  frequent  foreign  body  found  in  the  esophagus  is  a 


506  SURGERY    OF    THE    ESOPHAGUS    AND    STOiMACH 

poorly-fitted  dental  plate  which  had  not  been  removed  at  night  or  which 
had  been  swallowed  during  an  attack  of  syncope  or  convulsions. 

From  what  has  been  said  one  can  see  what  a  great  variety  of  foreign 
bodies  may  enter  into  consideration.  The  situations  at  which  foreign 
bodies  may  become  lodged  depends  considerably  upon  the  nature  and  size 
of  the  object.  Small  pointed  bodies  which  penetrate  the  mucous  membrane 
easily  may  lodge  at  any  point  along  the  esophagus.  Very  large  bodies  as  a 
rule  cannot  pass  the  isthmus  and  remain  lodged  in  the  pharynx.  Small, 
sharp-pointed  bodies,  like  fish-bones  and  wooden  splinters  which  project 
from  a  morsel  of  food,  are  apt  to  be  driven  into  the  wall  of  the  pharynx 
during  the  first  act  of  swallowing.  Large  bodies  which  pass  the  isthmus 
may  become  impacted  at  the  upper  border  of  the  cricoid  cartilage,  where 
the  esophagus  is  crossed  by  the  left  bronchus,  or  where  the  esophagus  passes 
through  the  diaphragm. 
Symptoms. 

The  symptoms  vary  according  to  the  situation  of  the  object,  according 
to  its  size  and  shape  and  the  amount  of  obstruction  present  and  also  to  the 
amount  of  pressure  exerted  upon  other  organs,  as  the  trachea  or  larynx. 
There  is  usually  nausea,  a  sense  of  obstruction  and  pain  on  attempting  to 
swallow  and  occasionally  a  reflex  cough.  If  the  body  is  large  and  remains 
in  the  pharynx  it  may  press  upon  the  opening  in  the  larynx  and  cause  chok- 
ing, accompanied  by  cyanosis,  etc. 

If  there  is  complete  obstruction  all  food  will  be  regurgitated.  When 
the  obstruction  is  high  up  in  the  esophagus  the  regurgitation  will  take  place 
immediately  on  attempting  to  swallow,  if  it  is  low  clown  a  little  time  may 
intervene  before  the  food  is  regurgitated. 

In  cases  in  which  the  foreign  body  has  sharp  edges  which  cause  injury 
the  patient  complains  of  a  stabbing  pain  at  a  definite  point  on  attempting  to 
swallow.  This  point  is  apt  to  be  the  location  of  the  obstruction  when  the 
foreign  body  is  situated  high  up. 

When  the  impaction  is  lower  down  the  pain  is  usually  referred  to  the 
region  of  the  sternum,  though  the  obstruction  may  be  at  a  lower  level. 

Diagnosis. 

Occasionally  a  positive  diagnosis  of  an  impacted  foreign  body  can  be 
made  from  the  history  and  symptoms.  On  account  of  the  serious  complica- 
tions that  may  arise  from  a  foreign  body  remaining  in  the  esophagus  a  long 
time,  an  attempt  should  be  made  even  in  doubtful  cases  to  determine  the 
presence  or  absence  of  such  a  substance. 

The  pharynx  should  be  inspected  by  means  of  a  mirror,  and  palpation 
made  with  the  finger.  External  palpation  should  be  made,  as  large  bodies 
in  the  cervical  portion  can  often  be  felt,  or  there  may  be  a  point  of  tender- 
ness corresponding  to  the  location  of  the  object. 

In  most  cases  a  foreign  body  can  be  found  by  passing  a  bougie,  also 
its  situation  determined  in  this  manner.  The  best  bougie  for  this  purpose 
is  a  whalebone  staff  with  a  cylindrical  tip  of  ivory  or  metal.  On  touching 
a  foreign  body  with  such  an  instrument  a  clicking  or  rubbing  sound  can 
be  beard  or  at  least  felt. 

Examination  with  the  X-ray,  either  by  means  of  the  fluoroscope  or 
X-ray  photograph,  is  an  important  aid  in  diagnosis  and  has  proved  to  be 
very  practicable  in  many  instances. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  507 

The  esophagoscope  may  be  used  in  these  cases  both  as  a  means  of  diag- 
nosis and  treatment. 

The  early  use  of  the  esophagoscope  for  the  removal  of  a  foreign  body 
must  be  strongly  urged.  During  the  first  day  or  two  after  a  foreign  body 
is  lodged  there  is  very  little  inflammation  present,  but  after  three  to  four 
days  or  a  week  inflammation  becomes  intense,  abscess  formation  occurs, 
perforation  of  the  wall  of  the  esophagus  is  apt  to  take  place,  and  above  all, 
after  a  short  time  the  inflammation  surrounding  the  foreign  body  makes  it 
difficult  to  extract.  So  whenever  a  foreign  body  is  lodged  in  the  esophagus 
in  an  inaccessible  position,  and  when  it  cannot  be  pushed  clown  or  brought 
up,  the  esophagoscope  should  be  used  at  once,  and  in  a  great  many  cases 
the  foreign  body  can  thus  be  extracted. 

Treatment. 

The  treatment  of  foreign  bodies  should  be  instituted  as  soon  as  the 
diagnosis  has  been  made.  The  various  methods  in  which  no  cutting  opera- 
tion is  concerned  should  be  tried  first,  namely,  extraction  through  the  mouth, 
forcing  the  foreign  body  down  into  the  stomach,  extraction  with  the  aid 
of  the  esophagoscope. 

Extraction  by  the  Aid  of  the  Esophagoscope. 

After  an  examination  of  the  esophagus  has  been  made  with  a  bougie 
and  the  location  of  the  foreign  body  has  been  determined,  esophagoscopy 
should  be  undertaken  with  the  intention  of  extracting  the  foreign  body 
through  the  mouth,  or  pushing  it  into  the  stomach. 

In  many  cases  a  foreign  body  may  be  removed  by  aid  of  the  esophago- 
scope, thus  avoiding  an  esophagotomy  or  possibly  a  gastrostomy. 

Esophagostomy  should  only  be  attempted  by  those  who  have  had  special 
training  and  have  mastered  the  technique. 

Pushing  the  Object  Down  Into  the  Stomach. 

A  foreign  body  should  not  be  pushed  down  into  the  stomach,  unless 
one  is  fairly  certain  that  the  procedure  will  not  be  a  disadvantage  to  the 
patient.  The  cases  in  which  this  method  is  justifiable  are  those  in  which 
the  foreign  body  is  smooth  and  is  not  too  large  to  pass  the  pylorus,  and 
where  it  cannot  be  easily  grasped  with  extraction  forceps.  Also  in  cases  of 
a  soft  body,  as  pieces  of  meat,  potato,  etc.  The  best  instrument  for  this 
purpose  is  the  ordinary  bougie  with  a  cylindrical  tip.  In  case  a  foreign 
body  passes  into  the  stomach,  or  is  pushed  down  into  the  stomach,  its  pas- 
sage will  be  facilitated  by  feeding  the  patient  mashed  potatoes  for  a  few 
days. 

Where  the  above  methods  are  unsuccessful,  or  in  cases  where  they  are 
contraindicated,  a  surgical  operation  should  be  performed.  Even  though 
the  foreign  body  is  such  that  it  will  not  likely  pass  the  pylorus  safely,  it  is 
justifiable  to  push  it  down  into  the  stomach  and  perform  a  gastrotomy  later, 
for  the  latter  operation  is  much  simpler  and  less  dangerous  than  any  ex- 
ternal procedure  for  impaction  in  the  esophagus. 

There  are  two  methods  of  approach,  one  by  an  external  esophagotomy 
and  the  other  by  a  gastrotomy.  The  selection  of  the  method  must  depend 
upon  the  location  of  the  impaction. 

As  a  rule  if  it  is  at  the  cricoid  cartilage  or  any  place  above  the  supra- 
^ternal  notch,  an  esophagotomy  should  be  performed;  if  below  the  sternal 
notch  a  gastrotomy. 


508  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

Esophagotomy. 

The  patient  is  anesthetized  and  placed  with  the  shoulders  well  raised 
and  a  sand  bag  under  the  neck  so  as  to  throw  the  head  somewhat  back- 
wards. An  incision  is  made  on  the  left  side  of  the  neck  corresponding  with 
the  anterior  border  of  the  sterno-mastoid  muscle.  It  is  carrried  directly 
down  to  the  muscle.  Blunt  dissection  is  now  used  until  the  anterior  belly  of 
the  myo-hyoid  muscle  is  reached.  This  muscle  and  the  sterno-thyroid  and 
sterno-hyoid  muscles  are  retracted  inwards.  The  lateral  wall  of  the  trachea 
can  now  be  felt  and  on  stretching  the  wound  open  the  esophagus  should  be 
seen  immediately  behind  the  trachea.  Great  assistance  in  locating  the 
esophagus  can  be  rendered  by  placing  a  bougie  with  a  large  bulb  in  the 
canal  and  pressing  toward  the  wound.  The  esophagus  is  now  separated 
from  its  connections  both  anteriorly  and  posteriorly  by  means  of  blunt 
dissection,  so  that  it  is  possible  to  bring  the  esophagus  up  near  the  edges 
of  the  skin  wound.  The  remainder  of  the  wound  is  now  packed  off  with 
small  pads  so  as  to  prevent  any  discharge  which  might  come  from  the 
esophagus  from  infecting  the  wound. 

An  incision  is  now  made  upon  the  bulb  and  the  cut  edges  of  the  esopha- 
gus grasped  by  means  of  two  mouse-toothed  forceps.  The  esophagus  is 
now  explored  by  means  of  the  fingers,  and  the  foreign  body  removed  by 
the  aid  of  a  curved  pair  of  esophageal  forceps.  Great  care  should  be  taken 
to  sponge  away  any  mucus  that  escapes  from  the  passage.  After  the  for- 
eign body  is  removed,  the  wound  in  the  esophagus  should  be  closed  with 
two  layers  of  catgut  sutures,  the  outer  row  being  Lembert's  stitches.  A 
small  drain  is  now  carried  down  to  the  esophagus  and  all  of  the  deep  struc- 
tures sutured  in  their  normal  position  with  catgut  and  the  skin  approxi- 
mated with  horsehair  stitches.  The  patient  should  receive  no  food  or  liquids 
by  mouth  for  a  week  or  ten  days.  In  well  preserved  patients  the  nourish- 
ment and  fluids  can  be  administered  per  rectum.  In  very  weak  individuals 
the  nourishment  may  be  given  by  passing  a  tube  through  the  nose  down  into 
the  stomach. 

The  prognosis  in  cases  of  esophagotomy  depends  mostly  upon  the  time 
of  operation.  If  this  is  done  within  the  first  24  to  48  hours  the  prognosis 
is  good.  If  after  this  time,  and  ulceration  or  perforation  has  taken  place, 
the  prognosis  is  very  grave. 

Gastrotomy. 

Removal  of  foreign  bodies  through  the  stomach  is  justifiable  in  all 
cases  in  which  such  body  is  situated  too  low  in  the  thoracic  portion  of  the 
esophagus  to  be  reached  by  esophagotomy,  and  which  cannot  be  removed 
by  other  means.  It  is  indicated,  therefore,  where  the  foreign  body  is  sit- 
uated more  than  26  cm.  from  the  teeth,  as  well  as  those  in  the  cardiac  end 
of  the  esophagus,  especially  in  large  angular  or  irregular-shaped  bodies. 

In  performing  gastrotomy  for  foreign  body  in  the  esophagus,  an  in- 
cision is  made  through  the  edge  of  the  left  rectus  abdominis  muscle  or 
obliquely  along  the  costal  margin.  Upon  opening  the  peritoneal  cavity  the 
intestines  should  be  packed  away  by  means  of  sterile  gauze  pads  to  guard 
against  soiling  the  peritoneum  by  any  leakage  from  the  stomach.  The 
dome  of  the  stomach  is  now  brought  forward  and  out  of  the  peritoneal 
cavity  if  possible.  The  stomach  wall  is  grasped  with  mouse-toothed  stomach 
forceps  and  then  incised.  The  stomach  contents  should  be  removed  by 
packing  dry  gauze  pads  in  and  out  through  the  opening  in  the  stomach  wall. 


SURGERY    OF    TIIK     KSnl'lIAGfS    AX1)    STOMACH  509 

The  lower  end  of  the  esophagus  is  now  explored  by  passing  one  finger 
through  the  stomach.  The  edges  of  the  stomach  wound  should  be  held  well 
beyond  the  edges  of  the  abdominal  wound  and  a  pair  of  esophageal  forceps 
passed  through  this  opening  up  into  the  esophagus  and  the  foreign  body 
extracted,  if  possible.  In  the  more  difficult  cases,  where  various  procedures 
are  necessary  in  order  to  loosen  and  bring  down  the  foreign  bodies,  it  is 
most  practicable  to  enlarge  the  incision  and  pass  the  whole  hand  into  the 
stomach,  as  recommended  by  Richardson.  If  the  foreign  body  cannot  be 
reached  with  the  finger  and  removed  by  the  aid  of  forceps,  the  string 
method,  as  used  by  Bull  and  Finney,  should  be  tried.  A  small  sound  or 
bougie  is  passed  either  through  the  mouth,  or  from  below  through  the 
gastrotomy  opening.  A  string  which  has  been  armed  with  a  small  sponge 
or  piece  of  gauze  is  attached  to  the  end  of  the  sound  and  pulled  back  through 
the  esophagus.  An  attempt  is  now  made  by  pulling  this  sponge  through 
the  esophagus  to  bring  the  foreign  body  up  and  out  through  the  mouth,  or 
pull  it  downwards  into  the  stomach.  After  the  foreign  body  has  been  re- 
moved, the  management  of  the  opening  in  the  stomach  depends  upon  the 
amount  of  traumatism  of  the  esophagus. 

If  the  foreign  body  is  removed  early  and  with  little  injury  to  the 
esophagus,  the  wound  in  the  stomach  should  be  completely  closed"  by  first 
placing  a  Connell  suture  through  the  two  edges  and  covering  the  area  with 
a  Lembert  stitch.  In  case  the  foreign  body  has  been  present  for  a  consid- 
erable time  so  that  it  might  have  caused  an  ulcerated  condition,  or  if  the 
esophagus  is  injured  considerably  during  the  removal  of  the  foreign  body, 
then  a  temporary  gastrotomy  should  be  done  for  the  purpose  of  administer- 
ing food  until  the  esophagus  has  recovered  from  the  injuries.  The  gas- 
trostomy  should  be  planned  so  that  the  opening  in  the  stomach  will  close 
spontaneously  in  a  short  time.  This  can  be  accomplished  by  carefully  fold- 
ing the  serous  surface  of  the  stomach  inwards  around  the  feeding  tube  so 
there  cannot  possibly  be  any  eversion  of  the  mucous  lining  of  the  stomach. 
If  this  is  done  in  the  manner  indicated  the  fistula  in  the  stomach  will  close 
in  a  short  time  after  removal  of  the  feeding  tube. 

The  most  important  complications  which  follow  the  swallowing  of  for- 
eign bodies  are  hemorrhage  and  phlegmonous  processes  resulting  from 
injury  to  the  esophagus,  ulceration,  perforation  or  gangrene  of  the  esopha- 
gus followed  by  a  phlegmonous  process  which  may  lead  to  suppuration  in 
the  pleura,  in  the  mediastinum,  in  the  loose  connective  tissue  between  the 
vertebral  column  and  the  esophagus  or  result  in  pneumonia  or  gangrene  of 
the  lungs. 

With  the  existence  of  any  of  the  above  complications  the  prognosis 
is  usually  unfavorable. 

STRICTURE  OF  THE  ESOPHAGUS. 

Of  the  actual  strictures  of  the  esophagus,  those  caused  by  carcinoma 
are  most  frequent,  the  next  in  frequency  being  cicatricial  stenosis,  the  result 
of  the  healing  of  an  ulceration.  The  latter  is  produced  by  some  form  of 
traumatism,  such  as  the  swallowing  of  caustic  alkali,  acids  or  hot  fluids. 
It  may  be  caused  by  a  wound  or  clue  to  prolonged  lodgment  of  a  foreign 
body.  It  is  occasionally  due  to  typhoid  ulceration. 

The  most  common  cause,  and  especially  in  children,  is  the  accidental 
swallowing  of  concentrated  Ive.  In  adults  carbolic  acid,  ammonia,  etc.,  are 


5IO  SURGERY    OF    THE    ESOPHAGUS    AND    STQMACH 

frequently  taken,  but  the  immediate  mortality  is  high  so  only  a  small  pro- 
portion live  to  develop  a  cicatrix.  Occasionally  the  breaking  down  of  a 
syphilitic  gumma  may  leave  an  ulcer,  and  the  healing  thereof  cause  a 
stenosis.  Tubercular  ulceration  of  the  esophagus  is  very  rare.  The  healing 
of  an  ulcer  of  the  cardia  extending  into  the  esophagus  may  in  rare  cases 
result  in  a  cicatricial  stenosis  of  the  esophagus.  Spasmodic  stricture  of  the 
esophagus  is  not  a  rare  condition  and  must  always  be  kept  in  mind  when 
considering  cases  of  obstruction  of  this  tube. 

A  pressure  stenosis  of  the  esophagus  may  result  from  extra-eso- 
phageal  conditions  such  as  tumors  involving  the  thyroid  body,  tracheal  and 
mediastinal  glands,  aneurysms,  pericardial  effusions,  peri-esophageal  abscess 
and  spondylitis. 

Although  strictures  may  occur  at  any  part  of  the  esophagus,  they  are 
most  frequently  found  at  the  site  of  the  three  natural  constrictions,  viz.,  at 
the  entrance,  at  the  level  of  the  bifurcation  of  the  trachea,  and  in  the  region 
of  the  hiatus. 
Symptoms. 

Difficulty  in  swallowing  is  present  in  all  cases  of  stricture  of  the 
esophagus.  The  degree  of  dysphagia  depends  upon  the  degree  of  stenosis. 
In  cases  of  cicatricial  stenosis  the  narrowing  usually  develops  slowly,  and 
the  dysphagia  comes  on  gradually.  At  first  the  patient  experiences  difficulty 
in  swallowing  solid  food,  especially  meat.  Early  in  the  disease  there  is 
usually  a  sense  of  pain  or  discomfort  in  the  esophagus  at  the  point  of  the 
stricture,  especially  during  the  act  of  swallowing.  Occasionally  the  patients 
locate  the  stricture  incorrectly,  as  the  pain  may  be  referred  to  the  region  of 
the  sternum  and  cricoid  cartilage  when  the  obstruction  is  in  the  lower 
portion  of  the  canal. 

As  the  stenosis  increases  the  difficulty  in  swallowing  becomes  more 
marked,  and  the  patient  soon  develops  a  rather  characteristic  symptom  of 
being  careful  to  take  only  a  small  amount  of  food  at  a  time,  and  then  swal- 
lowing slowly.  They  frequently  gag,  and  then  carry  out  certain  motions 
with  the  head.  There  is  frequently  regurgitation  of  food ;  if  the  obstruc- 
tion is  high  up  this  takes  place  immediately,  if  lower  down,  a  short  time  may 
intervene  before  the  regurgitation  occurs. 

Where  the  obstruction  is  very  marked  mucus  and  swallowed  saliva 
accumulate  constituting  a  great  annoyance  to  the  patient  by  being  frequently 
regurgitated  into  the  mouth.  As  soon  as  the  obstruction  is  pronounced, 
loss  of  weight  takes  place  from  lack  of  sufficient  nourishment. 

Diagnosis. 

In  mechanical  stricture  of  the  esophagus  there  is  present  a  series  of 
symptoms  which  are  self-evident ;  of  these  the  dysphagia  and  regurgitation 
of  food  are  the  most  prominent.  .When  a  patient  complains  of  difficulty  in 
swallowing,  or  of  vomiting  at  the  time  of  eating,  we  should  put  him  to  the 
test  and  observe  what  happens  during  the  ingestion  of  food'  and  drink. 
Even  though  the  obstruction  has  existed  but  a  short  time,  we  will  observe 
that  the  patient  has  learned  to  eat  slowly,  to  take  only  small  bites  of  food 
and  to  masticate  very  carefully.  If  the  stenosis  is  very  marked  even  liquids 
will  be  taken  slowly  and  it  will  be  evident  that  it  is  an  effort  to  cause  the 
food  to  go  down.  If  the  patient  is  urged  to  eat  more  rapidly  he  will  say 
that  it  is  impossible.  If  eating  is  forced  there  will  be  a  regurgitation  of 
food  usually  mixed  with  mucus.  This  takes  place  without  any  effort  on  the 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  511 

part  of  the  patient  and  is  very  different  from  the  expulsive  evidences  which 
accompany  ordinary  vomiting.  The  patient  can  practically  always  distin- 
guish the  difference  between  the  act  of  vomiting  and  that  of  regurgitation 
of  food. 

If  the  history  indicates  the  presence  of  a  stenosis  we  can  confirm  the 
diagnosis  by  passing  a  stomach  tube  or  bougie.  Before  such  instruments 
are  used  a  careful  examination  should  be  made  to  determine  if  there  is  any 
contraindication  to  the  passage  of  these  instruments. 

The  presence  of  an  aneurysm  or  high  grade  arterio-sclerosis  or  pro- 
nounced heart  incompetency  render  the  procedure  unsafe. 

As  a  rule  it  is  best  to  pass  a  soft  stomach  tube  first,  but  the  exact  loca- 
tion  and  degree  of  obstruction  may  be  more  accurately  determined  by  using 
bougies  with  olive  tips. 

The  diagnosis  and  location  of  an  esophageal  stenosis  is  usually  easy, 
but  to  determine  the  exact  nature  of  the  obstruction  is  often  a  difficult  mat- 
ter. In  adults  carcinoma  is  by  far  the  most  common  cause  of  stricture.  It 
is  characterized  by  the  symptoms  described  above,  its  onset  is  usually  gradual 
although  the  inability  to  swallow  solids  may  come  on  suddenly.  The  course 
of  carcinoma  is  progressive,  there  is  a  gradual  loss  of  weight  and  later 
cachexia.  Metastatic  growths  should  always  be  looked  for,  although  they 
are  rarely  of  value  in  the  early  diagnosis.  As  there  is  a  tendency  toward 
early  ulceration  in  carcinoma  the  presence  of  blood  in  the  stools  is  an  im- 
portant diagnostic  sign.  In  carcinoma  the  passage  of  even  a  soft  stomach 
tube  usually  causes  bleeding  on  account  of  its  ulcerating  surface. 

In  cicatricial  stenosis  there  will  be  a  gradual  and  persistent  obstruction 
with  the  absence  of  the  above  symptoms.  There  is  usually  a  history  of 
swallowing  caustic  acids  or  alkalies.  This  history  together  with  the  pres- 
ence of  a  firm  obstruction,  as  determined  by  passing  a  bougie,  will  usually 
suffice  to  make  the  diagnosis  of  cicatricial  stenosis. 

Treatment. 

Much  can  be  done  to  prevent  the  formation  of  troublesome  strictures 
following  trauinatisms  of  the  esophagus  by  treating  the  condition  before 
contraction  takes  place.  After  the  swallowing  of  caustic  substances,  sys- 
tematic sounding  should  be  instituted  in  from  two  to  four  weeks.  Foreign 
bodies  should  not  be  allowed  to  remain  in  the  esophagus  until  ulceration  has 
taken  place. 

Dilatable  Strictures. 

Gradual  dilatation  is  the  operation  of  choice  in  these  cases.  If  the 
stricture  is  not  too  tight  the  woven  flexible  bougies  are  suitable  for  this  pur- 
pose. The  bougie  is  lubricated  with  vaseline,  olive  oil,  or  glycerine  and  passed 
after  the  method  described  in  the  part  upon  examination  of  the  esophagus. 
In  the  tighter  strictures  a  bougie  with  a  whalebone  stem,  to  which  may  be 
attached  increasing  sizes  of  ivory  olive-shaped  tips,  will  be  found  most 
valuable.  The  tip  should  be  made  long  and  tapering  so  that  it  will  enter 
the  stricture  with  more  ease  than  the  ordinary  olive  tip.  There  are  many 
cases  in  which  the  woven  flexible  bougie  or  the  olive  tips  cannot  be  passed 
and  the  surgeon  is  apt  to  pronounce  the  case  one  of  impermeable  stricture. 
However,  in  these  cases  with  care  and  gentleness  a  filiform  bougie  can  easily 
be  passed,  even  though  several  sittings  are  required.  In  such  cases  several 
small  filiform  bougies,  on  one  end  of  which  threads  are  cut  so  as  to  be 
attached  to  a  flexible  dilator,  as  shown  in  Plate  LXV.  should  be  inserted  into 


512  SCRGKRV    OF    THE     KSOPHAGUS    AND    STOMACH 

the  esophagus  against  the  stricture  in  the  same  manner  as  filiforms  are  in- 
serted into  the  urethra.  Now  by  manipulating  first  one  bougie  and  then 
another,  one  will  usually  slip  through.  The  tapering  flexible  bougie  is  now 
attached  to  the  filiform  which  serves  as  a  guide  while  the  bougie  is  pushed 
on  through  the  stricture.  After  the  filiform  has  been  passed  a  few  times, 
the  passage  of  the  woven  flexible  bougie  or  the  olive  tips  can  probably  be 
accomplished.  These  should  be  passed  in  increasing  sizes  at  intervals  two 
or  three  times  a  week.  After  a  few  days  when  the  patient  has  become  accus- 
tomed to  this  procedure,  the  largest  flexible  bougie  passed  should  be  left  in 
place  for  a  period  of  five  to  fifteen  minutes. 

Many  months  are  usually  required  for  thorough  dilatation  of  one  of 
these  strictures,  and  after  the  patient  is  apparently  cured,  sounds  should  be 
passed  occasionally  for  several  years. 

Non-Dilatable  Strictures. 

In  strictures  which  are  impermeable  from  above,  or  cannot  be  success- 
fully treated  by  dilatation  through  the  mouth,  the  treatment  depends  upon 
the  condition  of  the  patient  and  upon  the  location  of  the  stricture.  If  the 
patient  is  in  an  exhausted  state  from  prolonged  starvation,  a  temporary 
gastrostomy  should  be  performed,  and  the  patient  nourished  in  this  way 
until  his  general  condition  has  improved.  By  this  means  rest  is  given  to  the 
affected  parts  and  later  on  it  may  be  possible  to  dilate  the  stricture  from 
above,  and  if  not,  some  form  of  retrograde  dilatation  may  be  used. 

The  most  common,  as  well  as  the  most  serious,  strictures  are  those  at 
the  lower  end  of  the  esophagus.  The  best  method  of  dealing  with  these  is 
some  form  of  retrograde  dilatation. 

Esophageal  strictures  which  are  impermeable  from  above,  will  almost 
invariably  permit  the  passage  of  a  bougie  from  below,  because  the  pressure 
of  the  food  in  trying  to  pass  down  the  esophagus  renders  the  canal  basin- 
shaped,  while  on  the  distal  side  it  is  funnel  shaped,  thus  naturally  a  bougie 
will  pass  more  readily  upwards  through  the  stricture. 

The  Cchsner  Method. 

The  same  incision  is  made  as  used  in  ordinary  gastrostomy.  The 
stomach  wall  is  brought  out  of  the  wound  and  a  purse-string  suture  applied 
to  describe  a  circle  one  and  one-half  inches  in  diameter.  An  incision  is 
made  in  the  stomach  wall  large  enough  to  admit  one  finger.  A  filiform 
bougie  is  now  passed  through  the  stricture  either  from  above  or  in  a  retro- 
grade manner.  A  silk  cord  is  attached  to  the  end  of  the  bougie  and  pulled 
up  through  the  esophagus  and  out  through  the  mouth.  A  stronger  silk  cord 
is  attached  to  this  one  and  in  turn  is  drawn  through  downwards.  This  per- 
formance is  repeated  until  a  verv  powerful  silk  cord  has  been  drawn  through 
double  and  tied  upon  itself,  as  shown  in  Fig.  20.  The  feeding  tube  is 
fastened  in  the  stomach  bv  tying  the  purse-string.  The  silk  cord  is  left  in 
place,  passing  around  through  the  esophagus  and  stomach  and  out  along 
side  the  feeding  tube,  so  that  it  cannot  be  dislodged  by  an  accidental  manipu- 
lation. The  operation  is  then  completed  by  suturing  the  stomach  to  the 
peritoneum  and  transversalis  fascia. 

The  feeding  tube  is  left  in  place  for  a  few  days  while  the  stomach  is 
becoming  thoroughly  attached  to  the  abdominal  wall,  during  which  time  the 
patient  receives  an  abundance  of  nourishing  food. 

The  dilatation  is  now  begun  in  the  following  manner;  by  means  of  the 
continuous  double  cord  another  cord  is  carried  through  the  stomach  into  the 


Fig.  20. 

DILATATION   OF   STRICTURE  OF  OF.SOPHAGUS. 

Shows  continuous  double  thread  of  heavy  braided  silk  passed  through  mouth, 
pharynx,  esophagus,  stomach,  gastrostomy  wound,  and  from  this  to  the  mouth,  a 
rubber  drainage  tube  being  drawn  through  the  loop  in  the  string  for  the  purpose  of 
dilating  the  stricture,  and  a  second  drainage  tube  being  drawn  through  the  loop  made 
by  the  first. 

For  the  dilatation  of  a  stricture  in  the  lower  end  of  the  oesophagus  it  has  been 
suggested  that  the  stomach  be  opened  after  the  method  just  described  and  that  then  a 
dilator  formed  after  the  pattern  of  a  glove-stretcher  be  passed  through  the  stricture 
from  below  and  the  latter  very  thoroughly  and  repeatedly  dilated;  great  care  being 
taken  however  not  to  tear  but  simply  to  stretch  the  tissues,  which  can  be  accomplished 
only  if  the  dilatation  is  made  very  slowly  and  is  very  frequently  repeated. 


Fig.  21. 

DILATATION  OF  STRICTURE  OF  OESOPHAGUS. 

The  same  as  Fig.  20,  a  larger  double  rubber  drainage  tube  having  been  drawn 
through  the  loop  in  the  first  and  left  in  the  stricture  temporarily  for  the  purpose  of 
dilating  the  latter. 

The  number  and  the  size  of  these  tubes  may  be  increased  until  the  desired  degree 
of  dilatation  has  been  accomplished.  It  is  important  that  they  should  be  left  in  place 
in  the  stricture  for  several  minutes  after  they  have  been  drawn  into  this  in  order  to 
secure  the  dilatation  which  comes  from  the  elasticity  of  the  rubber  tubing. 


Fig.  22. 

DILATATION  OF  STRICTURE  OF  OFSOPHAGUS. 

Barnes'  dilator  introduced  after  a  partial  dilatation  has  been  accomplished  by  the 
methods  illustrated  in  Figs.  20  and  21.  The  stop-cock  enables  the  surgeon  to  distend 
the  bag  and  to  keep  it  distended  for  any  desired  time  while  engaged  in  the  stricture. 


Fig.  23. 

DILATATION  OF   STRICTURE  OF  OESOPHAGUS. 

Barnes'  uterine  dilator  in  position;  (s)  shows  the  stop-cock,  which  maintains  a 
constant  degree  of  dilatation. 

When  the  destruction  is  at  the  point  indicated  in  this  figure,  that  is  opposite  the 
point  at  which  the  oesophagus  passes  through  the  diaphragm,  it  has  been  suggested  that 
the  stricture  may  be  due  to  circular  constriction  of  the  muscles  of  the  diaphragm  sur- 
rounding the  oesophagus,  and  in  one  case  at  least  the  careful  division  of  these  muscle 
bands  has  resulted  in  a  cure  of  the  stricture. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  521 

esophagus  and  out  through  the  mouth.  This  cord  should  again  be  double 
so  that  a  rubber  drainage  tube  may  be  looped  into  it  and  drawn  through  the 
stricture,  as  shown  in  Fig.  20.  In  this  figure,  however,  the  rubber  tube 
is  looped  directly  upon  the  original  silk  cord,  which  is  not  a  safe  practice, 
because  in  case  the  cord  should  break  it  might  be  difficult  to  replace  it,  while 
there  is  no  danger  of  its  breaking  in  simply  carrying  through  another  cord. 
The  rubber  will  stretch  out  into  a  thin  body  when  drawn  through  a 
tight  stricture,  but  when  relaxed  will  act  as  a  powerful  dilator.  The  size 
of  the  rubber  tube  may  be  increased,  or  any  desired  number  may  be  drawn 
through  the  stricture  at  the  same  time,  as  the  calibre  of  the  latter  increases 
as  in  Fig.  21.  The  rubber  tubes  may  be  drawn  back  and  forth,  the  first 
one  is  drawn  through  the  mouth  and  out  of  the  opening  in  the  stomach  by 
means  of  the  silk  cord.  The  dilatation  can  now  be  carried  on  by  looping 
a  larger  rubber  tube  through  the  loop  of  the  other  tube  and  by  means  of 
the  latter  draw  the  larger  tube  up  through  and  out  of  the  mouth,  and  then 
repeat  this  until  as  large  a  tube  as  desired  is  drawn  through  the  stricture. 
This,  however,  requires  a  large  opening  in  the  stomach,  which  is  not  neces- 
sary if  the  tubes  are  simply  looped  into  the  silk  cord  and  by  alternating  the 
direction  of  the  pull  the  tube  is  drawn  out  by  its  free  ends  and  in  by  the  silk 
loop.  Later  on,  a  Barnes  dilator  in  a  collapsed  condition  may  be  drawn  into 
the  stricture,  as  shown  in  Fig.  22.  In  this  plate  the  dilator  was  drawn 
up  from  below  but  it  can  be  drawn  down  from  above  with  no  more  diffi- 
culty. The  fact  that  the  dilator  is  engaged  in  the  stricture  can  be  recognized 
by  the  difficulty  one  experiences  in  drawing  it  into  the  narrow  opening,  and 
the  shoulders  upon  the  bag  create  a  tendency  to  keep  it  from  slipping  beyond 
the  stricture. 

When  once  in  place  the  Barnes  dilator  may  be  inflated  with  air  by 
means  of  a  rubber  bulb.  The  patient's  own  feelings  must  serve  as  a  guide 
to  the  degree  of  dilatation  it  is  safe  to  make  use  of  at  any  given  time,  and 
the  length  of  time  it  is  wise  to  leave  the  dilator  in  place. 

Sippy  has  constructed  a  dilator  superior  to  the  Barnes,  which  can  be 
used  in  the  same  manner.  This  consists  of  a  rubber  bag,  about  three  and 
one-half  inches  long,  encased  in  a  silk  bag,  which  limits  accurately  the  dis- 
tension produced.  When  inflated  with  air  the  circumference  of  the  silk  bag 
is  about  15  cm.  The  dilating  force  is  accurately  controlled  by  the  silk  bag, 
and  the  maximum  pressure  exerted  at  the  point  desired.  The  silk  bag  is 
covered  with  a  rubber  bag  to  prevent  friction. 

If  simple  dilation,  either  by  the  use  of  the  rubber  tubes  or  the  Barnes 
dilator,  does  not  expand  th«  stricture  rapidly  enough,  the  edges  of  the 
stricture  may  be  rendered  tense  either  by  drawing  a  number  of  rubber 
tubes  into  the  stricture  or  by  the  inflated  bag,  as  shown  in  Fig.  23,  and 
then  using  the  silk  cord  after  the  fashion  of  a  chain  saw,  similar  to  the 
method  of  Abbe,  thus  cutting  the  edges  of  the  stricture. 

After  a  considerable  degree  of  dilatation  has  been  accomplished  it  is 
well  to  attempt  the  passage  of  esophageal  bougies  from  above.  These 
should  be  passed  every  day  at  first,  then  once  a  week  for  several  months  and 
then  once  a  month  for  many  years.  The  patient  may  be  taught  to  pass  the 
bougies  himself  and  then  to  report  personally  to  the  surgeon  occasionally, 
because  he  often  imagines  that  he  has  succeeded  in  passing  a  bougie  when  lie 
has  only  introduced  it  down  to  the  stricture. 

After  removing  the  feeding  tube  in  these  cases  in  which  an  adequate 


522  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

passage  through  the  esophageal  stricture  has  been  established  by  dilatation, 
the  opening  in  the  stomach  will  usually  close  spontaneously. 
Abbe's  String  Cutting  Method. 

The  abdomen  is  opened  and  the  anterior  wall  of  the  dome  of  the 
stomach  is  brought  up  and  sutured  to  the  edges  of  the  abdominal  wall.  An 
opening  is  made  in  the  stomach  and  two  fingers  are  inserted  into  the  viscus 
and  passed  along  its  anterior  wall  to  locate  the  opening  of  the  esophagus. 

Abbe  (Med.  Rec.,  Nov.  20,  1907)  calls  attention  to  the  fact  that  it  is 
often  difficult  to  locate  the  esophageal  opening.  In  connection  with  this 
Abbe  states:  "This  has  been  interesting  to  me  from  a  physiological  point 
of  view.  We  ordinarily  think  of  the  stomach  as  pictured  in  anatomy,  show- 
ing a  funnel-shaped  expansion  of  the  esophagus  where  it  joins  the  stomach 
wall.  It  has  never  been  my  experience  to  find  this  condition  in  the  living 
stomach.  As  the  finger  passes  back  and  forth  over  its  upper  interior  aspect, 
one  feels  an  even  surface  more  like  the  interior  of  any  dome-shaped  cavity. 
This  surface  is  maintained  by  the  circular  sphincteric  muscle  layers,  and  it 
is  not  until  a  moment's  pressure  of  the  finger  at  the  right  place  causes  them 
to  yield  that  it  slips  upward  into  the  esophagus. 

''I  have  never  seen  this  point  stated  in  surgical  works,  and  it  has  inter- 
ested me  as  representing  an  always  present  physiological  condition  which 
prevents  food  regurgitation." 

When  the  esophageal  opening  has  been  located,  a,  long  filiform  whale- 
bone bougie  guided  by  the  index  finger  is  passed  up  along  the  esophagus 
from  the  stomach  to  the  mouth.  To  the  end  of  this  a  heavy  silk  string  is 
tied  and  pulled  up  through  and  out  the  mouth.  A  tapering  bougie  is  now 
passed  up  along  the  string  and  through  the  stricture  until  it  becomes  wedged 
tight  in  the  strictured  portion.  The  string  is  now  pulled  backwards  and 
forwards  like  a  saw,  thus  cutting  the  tight  stricture  band.  As  the  stricture 
gives  way,  the  bougie  is  passed  farther  up  until  it  again  becomes  tight 
and  the  string  sawing  is  repeated  until  a  large  bougie  can  be  passed 
from  the  stomach  to  the  mouth.  In  place  of  passing  the  bougie  up  along 
the  string,  as  described  above,  a  second  string  may  be  drawn  through  the 
esophagus  to  the  lower  end  of  which  a  Billroth  dilating  bougie  is  tied,  and 
by  means  of  this  string  the  bougie  is  drawn  upwards  until  it  becomes  tightly 
engaged  in  the  stricture  and  then  the  sawing  process  used  as  above. 

The  fundamental  principle  of  this  operation  is,  that  the  dilator  must  be 
pressed  tightly  into  the  stricture  in  order  that  the  string  moving  to  and  fro 
may  cat  its  way  through  the  stricture.  No  tissue  will  be  affected  by  the 
string,  except  where  it  is  on  the  stretch. 

The  gastrostomy  opening  may  be  closed  immediately  after  the  cutting 
process  is  completed,  or  it  may  be  left  open  for  a  few  days  until  it  is  dem- 
onstrated that  a  large-sized  bougie  can  be  readily  passed  from  above. 
Bougies  should  be  passed  every  other  day  at  first,  then  weekly,  then  once  a 
month  for  a  year  and  after  that  once  each  year. 
Billroth's  Method. 

A  filiform  bougie  is  passed  into  a  gastrostomy  opening  and  up  through 
the  stricture  to  the  mouth,  or  out  through  an  external  esophagotomy  open- 
ing, and  a  strong  thread  drawn  down  through  and  out  of  the  gastric  open- 
ing. Then  to  the  lower  end  are  fastened  in  succession  conical  bougies  whose 
tips  are  capped  by  a  metal  point  into  which  the  string  is  tied.  From  the 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  523 

smallest  to  the  largest  ones  they  are  thus  safely  drawn  up  through  the 
stricture,  with  no  danger  of  perforating  the  wall  of  the  esophagus. 

In  performing  any  of  the  retrograde  methods  of  dilatation  one  is  apt 
to  have  difficulty  in  passing  the  first  string  through  the  stricture.  It  may 
not  only  be  impossible  to  pass  a  bougie  from  above,  but  one  may  also  experi- 
ence great  difficulty  in  finding  the  cardiac  opening.  In  such  cases  a  silk 
thread  may  be  floated  through  from  above,  as  advocated  by  Dunham.  This 
is  accomplished  by  having  the  patient  swallow  a  silk  thread  down  to  the 
stricture.  The  patient  is  now  given  a  swallow  of  water.  As  this  trickles 
down  through  the  stricture  it  may  carry  the  thread  through  with  it,  and 
then  the  thread  can  be  fished  out  through  the  gastric  fistula. 

DIVERTICULA   OF  THE   ESOPHAGUS. 

Diverticula  of  the  esophagus  are  pouch-like  sacculations  of  a  portion 
of  the  circumference  of  the  tube.  The  characteristic  features  of  a  true 
diverticulum  are  sharply-defined,  pouch-like  protrusions  of  the  esophageal 
wall,  lined  with  mucous  membrane. 

The  symptoms  vary  according  to  the  location  of  the  diverticulum.  If  it 
is  situated  in  the  cerical  portion  the  early  symptoms  may  be  only  slight, 
such  as  dryness  and  irritation  about  the  throat.  Later  the  sensation  of  a 
foreign  body  may  be  present.  As  the  sacculation  becomes  larger,  the  food 
accumulated  therein  crowds  against  the  esophagus  and  obstructs  its  lumen, 
causing  difficulty  in  swallowing  and  regurgitation  of  food.  In  about  one- 
third  of  the  cases  a  tumor  can  be  discovered  in  one  side  of  the  neck  after 
eating. 

The  majority  of  the  patients  learn  that  by  holding  the  head  in  a  certain 
position  they  may  be  able  to  swallow ;  others  learn  to  empty  the  sac  by 
making  pressure  upon  it  with  the  hand.  It  frequently  requires  hours  for 
a  meal.  In  some  cases  a  peculiar  gurgling  sound  is  heard  during  the  act  of 
swallowing.  In  most  cases  there  is  a  constant  retention  of  particles  of  food 
in  the  sac,  causing  a  fetor  which  may  become  intolerable.  It  is  often  noticed 
that  the  patient  can  swallow  better  during  the  early  part  of  the  meal.  As 
the  sac  fills,  it  crowds  upon  the  esophagus  and  obstructs  its  lumen. 

Diagnosis. 

The  diagnosis  can  usually  be  made  from  the  above  symptoms.  The 
history  of  the  gradual  development  of  these  disturbances  and  the  regurgita- 
tion of  unaltered  food  should  always  arouse  suspicion  of  a  diverticulum.  If 
a  tumor  develops  in  the  neck  during  a  meal  and  can  be  emptied  by  pressure, 
it  is  still  more  probable  that  a  diverticulum  is  present.  If  a  bougie  is  passed, 
it  is  usually  arrested  at  a  point  near  the  cricoitl  cartilage.  If  the  bougie  is 
slightly  withdrawn  and  the  direction  of  its  point  changed,  it  may  pass  on 
into  the  stomach.  It  frequently  happens  that  a  bougie  may  pass  readily  one 
day  and  not  the  next.  Occasionally  when  a  bougie  has  been  introduced 
into  the  diverticulum  a  second  bougie  may  at  the  same  time  be  passed  on 
into  the  stomach.  This  would  be  impossible  if  there  was  a  stenosis.  Bis- 
muth suspended  in  oatmeal  gruel  may  be  administered  and  an  X-ray  picture 
taken.  If  the  sacculation  is  sufficient  the  picture  will  show  the  location  and 
approximate  size. 

The  symptoms  of  the  deep-seated  diverticula  are  vomiting  or  regurgi- 
tation of  food  during  or  soon  after  the  meal.  After  vomiting  the  patients 


524  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

are  again  able  to  eat  for  awhile.  Occasionally  it  is  found  that  after  eating 
a  small  quantity  of  food  there  is  a  sense  of  weight  or  pressure  in  the  region 
of  the  sternum.  These  disturbances  gradually  increase  and  larger  quanti- 
ties of  food  are  vomited  and  less  food  enters  the  stomach  so  that  the  patient 
gradually  becomes  emaciated. 

The  diagnosis  is  based  upon  the  clinical  history  and  examination  with 
bougies.  For  this  purpose  a  bougie  with  a  curved  tip,  like  a  Mercier  catheter, 
is  most  convenient.  With  these  bougies  it  is  usually  easy  to  pass  by  the 
diverticulum  or  by  turning  the  point  pass  into  the  sacculation,  and  also 
determine  whether  the  diverticulum  is  situated  to  the  right  or  the  left.  A 
bismuth  mixture  may  be  administered  and  an  X-ray  photograph  taken  for 
the  purpose  of  determining  the  size  and  location. 
Treatment. 

The  treatment  of  esophageal  diverticula  in  the  cervical  region  may  be 
non-operative  or  surgical.  The  non-operative  consists  in  the  persistent  use 
of  sounds  and  stomach  tubes.  Permanent  benefit  to  the  patient  can  rarely 
be  expected  by  this  method. 

The  surgical  treatment  may  be  palliative  or  radical.  The  palliative 
treatment  consists  in  performing  a  gastrostomy  to  secure  a  means  of  ad- 
ministering food.  When  the  patient  is  in  a  bad  general  condition,  it  may 
be  advisable  to  perform  a  temporary  gastrostomy  in  order  to  be  able  to 
improve  his  general  condition  preparatory  to  the  radical  operation. 

This  also  affords  a  method  of  administering  food  other  than  by  the 
mouth,  until  the  wound  in  the  esophagus  has  healed. 

Extirpation  of  the  sac,  as  first  suggested  by  Kluge,  is  considered  the 
best  method  for  the  permanent  cure  of  this  condition.  The  chief  danger  of 
the  operation  seems  to  be  from  infection,  which  may  occur  from  the  con- 
tents of  the  sac  during  its  removal,  or  from  leakage  from  the  esophageal 
wound  after  it  has  been  sutured. 

The  technique  of  the  operation  is  as  follows  :  An  incision  is  made  along 
the  anterior  border  of  the  sterno-cleido-mastoid  muscle  from  the  level  of 
the  hyoid  bone  to  the  clavicle.  The  esophagus  is  reached  by  means  of  blunt 
dissection.  No  vessels  of  any  importance  are  encountered  except  the  supe- 
rior thyroid  and  occasionally  the  inferiod  thyroid.  Either  one  or  both  of 
these  may  be  ligated.  The  thyroid  gland  can  be  drawn  to  one  side  and  if 
not  enlarged  will  not  be  in  the  way.  The  sac  when  located  should  be  care- 
fully enucleated  like  that  of  a  hernia.  The  most  important  step  in  the  oper- 
ation is  the  closing  of  the  esophaghus  after  removal  of  the  diverticulum. 
Probably  the  best  method  is  that  similar  to  an  intestinal  suture  in  separate 
layers,  first  the  mucosa.  then  muscular  coat  and  finally  the  adventitia,  using 
catgut  for  the  first  two  layers  and  silk  for  the  last  suture. 

It  is  advisable  to  drain  the  wound  by  carrying  a  piece  of  iodoform 
gauze  or  cigarette  drain  from  the  esophageal  suture  out  through  the  skin 
incision. 

The  treatment  of  epibranchial  diverticula  and  those  located  just  above 
the  diaphragm  is  unsatisfactory.  Irrigation  with  mild  antiseptic  solution 
will  prevent  irritation  and  ulceration  of  the  mucous  membranes.  These  irri- 
gations and  the  passage  of  bougies  often  afford  considerable  relief. 

IDIOPATHIC  DILATATION  OF  THE    ESOPHAGUS. 

By  idiopathic  dilatation  of  the  esophagus  is  meant  a  dilatation  with  no 


PLATE  LXXI. 
Plummer's   whalebone   staff   with   ivory  tip  drilled   and   threaded   passing  through 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  527 

ascertainable  organic  cause.  The  esophagus  usually  becomes  dilated  through- 
out a  large  portion  of  its  extent,  sometimes  involving  practically  its  entire 
length  in  a  spindle-shaped  or  cylindrical  manner.  Our  lack  of  knowledge 
of  the  etiology  of  this  condition  is  indicated  by  the  variety  of  names  under 
which  the  cases  have  been  reported,  such  as  cardiospasm,  idopathic,  fusiform, 
diffuse  dilatation  and  dilatation  without  anatomical  stenosis.  Clinically,  as 
far  as  we  can  judge  from  the  history  of  these  cases,  a  definite  spasm  of  the 
cardia  seems  to  be  one  of  the  earliest  manifestations  of  the  disease. 
Etiology. 

The  cause  of  the  spasm  is  a  matter  of  speculation.  In  the  majority  of 
the  cases  a  definite  etiological  factor  cannot  be  found.  A  few  cases  have 
been  reported  associated  with  gross  lesions  of  the  esophagus  such  as  ulcers, 
fissures,  carcinoma  of  the  cardia  and  of  the  stomach.  Plummer  has  found 
three  cases  of  carcinoma  complicated  by  cardiospasm  and  one  case  of  hour- 
glass stomach  due  to  syphilis  with  secondary  cardiospasm.  In  his  study  of 
forty  cases  of  cardiospasm  only  three  of  the  cases  had  neurasthenic  symp- 
toms, and  evidence  of  esophagitis  previous  to  the  onset  of  the  cardiospasm 
could  not  be  elicited  from  any  of  them. 

Symptoms.     Three  Stages. 

The  symptoms  of  cardiospasm  may  be  divided  into  three  stages ;  first, 
cardiospasm  with  some  difficulty  in  swallowing  but  no  regurgitation  of 
food ;  second,  cardiospasm  with  immediate  regurgitation  of  food ;  third, 
cardiospasm  with  the  dilated  esophagus  with  retention  of  food  in  its  dilated 
portion  and  its  regurgitation  at  irregular  intervals. 

In  the  majority  of  cases  the  first  attack  of  spasms  occurs  suddenly  while 
eating.  A  spasmodic  choking  sensation  is  experienced  at  some  point  along 
the  course  of  the  esophagus,  most  often  located  in  the  region  of  the  cardia. 
This  sensation  is  rarely  described  as  a  pain  and  may  be  referred  entirely 
to  the  epigastric  region  or  to  the  upper  portion  of  the  esophagus.  Some- 
times the  spasm  is  described  as  a  delay  in  the  passage  of  food,  or  that  the 
food  "sticks7'  beneath  the  sternum.  Soon  it  is  noticed  that  the  patient  eats 
very  slowly  and  finds  it  difficult  to  swallow.  It  may  be  necessary  to  wash 
the  food  down  with  water.  The  patient  may  go  through  certain  movements 
of  the  body  and  arms  or  take  deep  breaths  to  force  the  food  down. 

In  the  second  stage  the  patient  has  regurgitation  of  food  which  occurs 
immediately  after  swallowing.  During  the  early  portion  of  the  history  the 
attacks  occur  periodically,  but  with  varying  degrees  of  intensity  and  with 
remissions  or  intermissions  covering  days,  weeks,  months  or  even  years. 
The  condition  pursues  its  slow  and  unmodified  course.  As  the  cardiospasm 
becomes  more  complete,  the  regurgitation  of  food  and  secretions  of  the 
esophagus  come  on  more  frequently  and  more  regularly. 

In  the  third  stage  after  dilatation  takes  place  the  spasmodic  choking 
sensation  may  be  absent.  The  patient  is  able  to  take  the  first  portion  of  his 
meal  quite  comfortably,  but  the  food  is  retained  in  the  dilated  esophagus  in- 
stead of  passing  on  into  the  stomach.  After  the  sac  is  filled,  further  food  is 
regurgitated  or  forces  some  of  the  preceding  portion  into  the  stomach.  Of 
the  contents  of  the  esophagus  at  the  close  of  a  meal,  the  more  fluid  portion 
may  gradually  slip  through  into  the  stomach.  The  solid  food  with  mucus 
is  usually  regurgitated  later  at  irregular  intervals.  Solid  food  like  meats 
may  remain  in  the  esophagus  several  days.  Plummer  states  that  the  sac 


528  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

never  completely  empties  itself  and  that  on  many  occasions  he  has  with- 
drawn from  two  to  sixteen  ounces  of  food  after  the  patient  has  fasted  for 
twenty-four  to  thirty-six  hours.  The  regurgitation  is  often  looked  upon 
as  vomiting  both  by  the  patient  and  the  physician.  Some  patients  insist  that 
the  food  enters  the  stomach  but  will  not  stay,  while  others  state  that  it  lodges 
beneath  the  sternum.  They  practically  all  complain  of  a  sense  of  weight  and 
discomfort  in  the  chest  and  will  also  maintain  that  the  regurgitated  food  is 
not  sour. 

Diagnosis. 

The  diagnosis  of  cardiospasm  is  apt  to  be  difficult  in  the  beginning, 
especially  in  patients  who  might  be  supposed,  on  account  of  their  age,  likely 
to  suffer  from  carcinoma  of  the  cardia.  But  in  advanced  cases  the  diagnosis 
should  not  be  difficult.  Generally  the  diagnosis  can  be  premised  from  the 
history.  Without  previous  warning  there  is  sudden  difficulty  in  swallowing, 
or  the  patient  unconsciously  gets  to  nibbling  and  following  each  deglutition 
of  solid  food  with  a  swallow  of  water.  At  first  liquids  are  often  swallowed 
with  greater  difficulty  than  solids.  After  dilatation  takes  place  the  obstruc- 
tion is  present  alike  to  liquids  and  solids. 

An  important  diagnostic  feature  is  that  there  may  be  little  or  no  ob- 
struction to  the  passage  of  a  bougie  even  in  cases  in  which  a  large  quantity 
of  food  is  retained  in  the  esophagus.  In  the  average  case  when  a  sound  is 
passed,  it  will  be  temporarily  arrested  at  the  cardia  and  then  when  slight 
pressure  is  made  it  passes  on  into  the  stomach.  A  large  bougie  will  often 
pass  as  easily  as  a  small  one.  This  is  not  true  in  case  of  an  organic  stricture. 
For  these  cases  Plummer  has  devised  an  olive-tipped  bougie  passed  on  a 
silk  thread  as  a  guide.  (Plate  LXXI.) 

The  patient  slowly  swallows  six  yards  of  silk  thread.  This  passes  down 
through  a  sufficient  number  of  coils  of  intestine  to  prevent  its  withdrawal 
on  being  pulled  taut.  He  has  the  patient  swallow  three  yards  in  the  after- 
noon and  three  yards  on  the  following  morning.  In  this  manner  the  first 
portion  forms  a  snarl  in  the  esophagus  or  stomach,  which  passes  out  into 
the  intestines  during  the  night,  the  remaining  portion  passing  without 
snarling.  The  olive  tips  for  threading  on  this  string  are  drilled  from  the 
tip  to  one  side  of  the  base.  The  olive  tip  after  being  fastened  on  the  end 
of  a  whalebone  staff  is  threaded  upon  the  silk  thread  protruding  from  the 
mouth.  The  string  is  now  pulled  taut  as  the  sound  is  passed  on  down  the 
esophagus.  The  silk  thread  as  a  guide  points  the  bougie  directly  into  the 
cardiac  orifice  and  avoids  that  resistance  encountered  in  sliding  the  olive 
along  the  flaring  wall  of  the  esophagus  or  the  straightening  out  of  some 
fold  just  as  it  is  about  to  enter  the  cardia. 

The  character  of  the  resistance  met  with  at  the  cardia  is  of  the  utmost 
importance  in  the  differential  diagnosis  of  organic  and  spasmodic  stricture 
of  the  cardia. 

Excitement,  overwork  and  worry  are  factors  that  may  increase  the 
spasm.  The  patient  frequently  awakens  at  night  and  finds  food  upon  the 
pillow  or  finds  his  mouth  and  posterior  nares  filled  with  former  contents  of 
the  esophagus.  In  organic  stricture  the  retention  of  food  and  mucus  is  slight 
in  comparison  to  what  it  may  be  from  the  result  of  cardiospasm.  X-ray  pic- 
tures of  the  dilated  esophagus  may  be  obtained  by  having  the  patient  swallow 
bismuth  subnitrate  suspended  in  oatmeal  gruel,  until  the  choking  sensation 
occurs,  then  the  part  photographed. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  529 

Treatment. 

Forcible  dilatation  is  the  best  method  of  treating  cardiospasm.  Until 
recently  the  treatment  of  cardiospasm  has  consisted  in  such  ineffectual 
measures  as  looking  after  the  patient's  general  condition ;  placing  him  under 
the  best  hygienic  care ;  restricting  the  diet  to  fluid,  non-irritating  substances  -, 
effervescent  drinks ;  administering  sedatives ;  the  passing  of  large  bougies 
and,  as  a  last  resort,  performing  a  gastrostomy.  The  passage  of  bougies 
has  been  followed  by  good  results  in  some  cases,  but  if  there  is  much  dilata- 
tion of  the  esophagus  such  results  are  only  temporary.  It  is  impossible  to 
actually  stretch  the  orifice  by  passing  sounds,  because  one  cannot  pass  a 
bougie  large  enough  to  produce  actual  stretching  of  the  muscle  fibers. 
Sippy  Dilation  Method. 

Other  means  have  been  devised  to  stretch  the  cardia.  Sippy  has  con- 
structed a  dilatator  consisting  of  a  rubber  bag  about  10  cm.  long  encased 
in  one  of  silk,  which  limits  the  distension  produced.  When  inflated  the  cir- 
cumference is  about  15  cm.  With  this  bag  the  maximum  pressure  is  exerted 
at  the  desired  point.  The  silk  covering  is  encased  in  a  rubber  cover  to  pre- 
vent friction.  A  long  non-elastic  rubber  tube  is  attached  to  the  bag  at  one 
end  and  connected  with  an  air  pump  at  the  other.  It  is  essential  to  measure 
the  amount  of  pressure  within  the  bag  during  the  dilatation  and  this  is  ac- 
complished by  connecting  a  column  of  mercury  to  the  tube  between  the  bag 
and  the  pump.  The  exact  distance  of  the  cardia  from  the  incisor  teeth  is 
measured  by  a  bougie.  The  bag  in  a  collapsed  condition  is  carried  down 
into  the  cardia  by  means  of  a  whalebone  staff.  The  dilatation  is  now  ac- 
complished by  distending  the  bag  with  air.  The  cardia  will  stand  a  pres- 
sure of  500  mm.,  but  Sippy  has  found  that  from  100  to  300  mm.  of  pressure 
exerted  for  a  period  of  three  minutes  will  be  sufficient  to  afford  relief  in 
most  cases.  The  number  of  dilatations  ranges  from  one  to  ten.  This 
method  of  treatment  is  used  without  anesthesia. 

The  immediate  results  from  this  treatment  are  most  striking.  Usually 
the  patient  is  able  to  take  most  any  kind  of  food  at  the  first  meal  following 
the  dilatation.  Sufficient  time  has  not  elapsed  since  the  introduction  of  this 
procedure  to  formulate  definite  conclusions  as  to  the  ultimate  outcome.  In 
forty  cases  treated  by  Plummer,  twenty-nine  have  remained  well  and  in 
several  of  these  the  time  elapsed  since  the  dilatation  is  over  two  years.  In 
the  eleven  cases  in  which  the  symptoms  returned,  the  time  elapsed  after  the 
treatment  varied  from  three  to  seven  months.  There  has  been  no  recur- 
rence in  any  case  which  remained  well  for  one  year. 

SURGERY   OF  THE   STOMACH. 

General  Considerations. 

Stomach  surgery  at  the  present  time  is  instituted  to  a  very  large  extent 
for  the  purpose  of  overcoming  faulty  drainage  of  this  organ.  In  various 
ways  the  pylorus  may  become  obstructed,  so  that  the  contents  of  the 
stomach  cannot  pass  on  into  the  intestine  in  a  normal  way,  and  as  a  result 
there  is  first  a  compensatory  hypertrophy  of  the  walls,  then  a  dilatation 
with  an  accumulation  of  mucus  and  food  remnants  which  are  sure  to 
undergo  decomposition.  This  is  accompanied  by  the  formation  of  gas, 
which  will  further  increase  the  distension  of  the  stomach.  This  in  turn 
produces  a  deformity  in  the  outlines  of  the  stomach,  the  latter  taking  the 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

form  of  a  pouch  bending  downward,  which  increases  the  obstruction  to 
the  pylorus,  because  the  food  has  to  be  elevated  a  considerable  distance 
before  it  reaches  the  exit. 

The  normal  stomach  extends  obliquely  across  the  abdominal  cavity, 
the  cardiac  end  being  much  higher  than  the  pyloric.  The  lesser  curvature 
of  the  stomach  extends  almost  vertically  downwards  for  the  first  two-thirds 
of  its  extent,  slanting  only  very  slightly  toward  the  right,  beginning  at  the 
point  of  entrance  of  the  esophagus,  almost  the  entire  curve  being  confined 
to  the  third  nearest  the  pylorus.  The  greater  curvature  is  more  uniform 
and  extends  across  the  abdomen  at  an  average  angle  of  about  45°.  It  is  im- 
portant to  bear  this  in  mind,  because  it  explains  to  a  great  extent  the  increase 
in  the  obstruction  resulting  from  the  element  of  dilatation,  which  is  in  itself 
the  result  of  an  obstruction  to  the  pylorus.  It  further  explains  some  of  the 
unsatisfactory  results  which  are  apt  to  persist  after  the  primary  obstruction 
of  the  pylorus  has  been  relieved  by  a  plastic  operation  to  enlarge  this  orifice. 

The  pylorus  which  has  been  thus  enlarged  would  readily  permit  the 
stomach  contents  to  pass  if  the  stomach  still  had  its  normal  form  and 
position,  but  with  the  greater  curvature  forming  a  deep  pouch,  which  has 
resulted  from  the  obstruction,  the  emptying  of  this  organ  is  greatly  inter- 
fered with,  even  if  the  constriction  of  the  pylorus  no  longer  exists. 

The  principal  diseases  of  the  stomach  that  are  amenable  to  surgical 
treatment  are  carcinoma,  gastric  and  duodenal  ulcers  and  their  complications. 

Gastric  and  duodenal  ulcers  will  be  considered  together  because  the 
stomach  and  duodenum  belong  together  embryologically,  anatomically  and 
physiologically,  and  are  very  closely  related  pathologically. 

Embryologically  they  are  formed  from  the  foregut,  the  lowest  end  of 
which  is  marked  by  a  more  or  less  distinctly  developed  sphincter-like 
arrangement  of  the  circular  muscle  fibres  located  from  two  to  ten  centimeters 
below  the  entrance  of  the  common  duct  into  the  duodenum. 

Anatomically  they  are  separated  by  the  pyloric  sphincter,  which  makes 
itself  known  to  a  marked  extent  only  when  the  stomach  contains  food. 

Physiologically  both  the  stomach  and  the  duodenum  serve  the  purpose 
of  preparing  food  in  such  a  manner  that  it  can  be  readily  absorbed  during 
its  passage  through  the  remaining  portion  of  the  alimentary  canal.     There 
is  but  very  little  absorption  of  food  as  it  passes  through  these  cavities. 
Functions   of  the    Stomach. 

The  stomach  has  five  clearly  defined  functions,  which  must  be  borne 
in  mind  in  the  surgical  treatment  of  this  organ. 

1.  It  stores  the  food  taken  at  one  meal. 

2.  It   secretes   the   digestive   ferments  which   act   in   an   acid  medium 
which  it  also  supplies  in  the  form  of  free  hydrochloric  acid. 

3.  It   acts   as  a  mixing  machine  which   saturates   the   food  with  the 
digestive  ferments  and  hydrochloric  acid. 

4.  It  grinds  the   food   into  the  proper  consistency  for  the   next  step 
in  the  course  of  digestion. 

5.  To  a  very  slight  extent  it  absorbs  some  of  its  contents. 

The  duodenum  serves  simply  as  an  extension  of  the  stomach  in  which 
small  portions  of  the  food  are  again  subjected  to  a  mixing  process,  this 
time  with  the  alkaline  bile  and  pancreatic  juice. 

In  the  treatment  of  gastric  and  duodenal  ulcers,  it  is  of  the  greatest 
importance  constantly  to  bear  in  mind  these  anatomical  and  physiological 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  531 

facts,  because  it  is  plain  that  every  surgical  interference  must  in  a  measure 
disturb  the  normal  anatomical  conditions,  and  this  in  turn  must  result  in 
physiological  changes  which  are  abnormal.  Primarily  gastric  surgery  deals 
with  the  relief  of  obstruction  of  the  pylorus  which  is  in  some  way  secondary 
to  gastric  ulcer. 
Etiology  of  Gastric  Ulcer. 

It  has  been  accepted  by  those  who  have  had  the  greatest  amount  of 
experience  in  the  treatment  of  gastric  ulcer  that  traumatism  from  within  is 
the  chief  exciting  cause. 

A  vast  majority  of  these  ulcers  occur  in  the  pyloric  end  of  the  stomach 
which  acts  more  pronouncedly  as  the  grinding  machine  and  is  consequently 
much  more  exposed  to  trauma  than  other  portions  of  the  organ. 

Many  clinicians  and  pathologists  have  attributed  gastric  ulcer  to  the 
presence  of  thrombosis  or  embolism.  Attention  has  recently  been  directed 
to  this  etiologic  factor  again  by  the  excellent  work  of  Prof.  Payr  (Archiv. 
f.  Klin.  Chir.,  Vol.  84),  in  which  he  reviews  all  of  the  experiments  which 
have  been  made  during  the  past  half  century  in  this  connection. 

Another  factor  which  has  been  under  discussion  for  some  time  is 
the  theory  concerning  the  presence  or  absence  of  certain  substances  in  the 
blood  which  make  the  mucous  membrane  immune  against  the  digestive 
action  of  its  own  secretions.  It  has  been  suggested  that  in  the  presence  of 
these  bodies  a  traumatism  of  the  mucous  membrane  of  the  stomach  will 
heal  while  in  their  absence  an  ulcer  will  result. 

This  seems  to  be  borne  out  by  animal  experiments,  those  of  Fibrich 
and  those  of  Futterer  being  especially  interesting.  The  latter  author  seems 
to  have  proved  experimentally  that  traumatism  of  the  mucous  membrane  of 
the  stomach  results  in  ulcer  only  in  the  presence  of  general  anemia,  and 
that  by  overcoming  this  anemia  by  treatment  these  ulcers  will  heal  spon- 
taneously and  permanently.  So  long  as  there  is  no  recurrence  of  the 
anemia  there  is  no  recurrence  of  the  ulcer  according  to  this  author. 

There  seems  to  be  no  doubt  but  that  duodenal  ulcer  is  due,  in  the  vast 
majority  of  cases,  either  to  an  extension  past  the  pyloric  sphincter  of  a 
gastric  ulcer,  forming  what  is  usually  known  as  the  saddle-shaped  ulcer  of 
the  pylorus,  or  it  may  be  formed  through  the  corrosive  effect  of  the 
hyperacid  gastric  juice,  thus  virtually  becoming  a  peptic  ulcer. 

Ulcers  of  the  duodenum  also  occur  as  a  result  of  severe  burns  of  the 
skin  and  from  thrombosis  of  the  vessels  supplying  the  duodenum. 
Frequency    of    Occurrence. 

Mayo  and  others  have  demonstrated  that  there  is  a  much  greater  relative 
frequency  of  duodenal  ulcer  than  was  formerlv  supposed,  but  the  exact 
proportion  has  not  yet  been  established.  It  is  likely  that  many  duodenal 
ulcers  have  been  overlooked  in  the  past. 

Mechanics   of  Digestion. 

The  interesting  and  valuable  work  by  Cannon  during  the  past  ten 
years  should  be  studied  by  every  surgeon  to  obtain  a  correct  idea  of  the 
mechanics  of  digestion. 

It  is  only  by  a  just  comprehension  of  the  physiological  processes  of  the 
entire  act  of  food  digestion  that  one  can  safely  undertake  operative  inter- 
ference therewith. 


532  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

It  is  plain  that  this  normal  arrangement  must  be  of  great  value  and 
that  any  surgical  operation  which  interferes  with  any  portion  of  this 
machine  must  leave  the  digestive  apparatus  seriously  reduced  in  efficiency 
when  compared  with  the  normal.  From  this  fact  it  is  but  logical  to 
conclude  that  in  any  case  of  ulcer  of  the  stomach  or  duodenum  the  patient's 
digestive  apparatus  will  be  in  a  vastly  better  condition  to  perform  its 
physiological  functions  if  it  can  be  restored  to  normal  without  surgical 
interference.  In  the  early  stages  of  gastric  or  duodenal  ulcers,  experience 
has  shown  that  this  is  possible  in  a  large  majority  of  cases  if  dietetic, 
hygienic  and  medicinal  methods  are  carefully  and  persistently  employed. 
Experience  has  also  shown  that  many  of  these  cases  do  not  remain  per- 
manently cured  but  that  they  suffer  from  relapses  usually  more  severe  than 
the  primary  attack,  and  that  after  several  of  these  "cures"  and  subsequent 
relapses  many  ultimately  are  compelled  to  seek  relief  by  surgical  operations. 
This  may  be  explained  by  the  theory  that  they  were  only  apparently  and  not 
really  cured,  or  that  they  were  really  cured  and  that  later  the  same  conditions 
which  originally  caused  the  ulcer  to  appear  have  given  rise  to  the  recurrence. 

A  careful  study  of  the  history  usually  brings  out  the  fact  that  these 
patients  have  subjected  their  stomachs  to  dietetic  abuses,  that  they  have 
lived  under  bad  hygienic  conditions  as  regards  work,  rest  and  regular 
habits  of  life,  and  that  they  have  not  given  proper  attention  to  their  general 
health,  and  as  Futterer  claims,  become  anemic  as  a  result  of  these  abuses. 

On  the  other  hand  with  continued  control  of  the  hygienic  and  dietetic 
influences  by  a  physician  for  a  long  period  of  time,  it  is  commonly  possible 
to  train  the  patient  so  that  he  will  acquire  such  habits  of  diet  and  hygiene 
as  will  prevent  the  recurrence  of  an  ulcer  after  it  has  once  healed. 

These  injunctions  are  less  burdensome  to  the  patient  when  he  knows 
that  even  after  operative  treatment  he  would  still  be  compelled  to  observe 
more  or  less  rigid  precautions. 

ACUTE  ULCER  OF  THE  STOMACH. 

In  acute  ulcer  of  the  stomach  there  are  usually  two  very  definite 
symptoms.  The  first,  most  constant  symptom,  is  pain,  which  is  located  as  a 
rule,  about  half  way  between  the  ensiform  appendix  of  the  sternum  and 
the  umbilicus.  This  pain  is  at  first  intermittent  and  occurs  only  after  some 
indiscretion  in  diet.  During  this  stage  pain  can  be  elicited  upon  pressure, 
regardless  of  whether  the  stomach  be  disturbed  with  food  or  not. 

In  the  second  place  there  is  usually  some  hemorrhage.  This  may  be 
so  slight  that  the  blood  can  be  detected  only  upon  careful  examination  of  the 
stools,  or  it  may  be  so  profuse  as  to  give  the  stools  a  characteristic  appear- 
ance, or  it  may  be  so  severe  as  to  cause  nausea  and  vomiting,  in  which  case 
blood  will  appear  in  the  vomitus.  The  blood  lost  may  be  so  considerable  that 
the  patient  will  show  marked  anemia  within  a  few  days ;  but  this  symptom 
usually  disappears  in  a  short  time  if  the  hemorrhage  subsides. 

As  a  rule  rather  severe  gastric  hemorrhage  does  not  require  immediate 
operation.  In  nearly  all  of  these  cases  the  hemorrhage  will  cease  if  the 
patient  is  kept  absolutely  quiet  and  no  food  or  cathartics  are  given  by 
mouth. 

These  patients  will  stand  operation  much  better  after  they  have 
recovered  from  their  loss  of  blood.  The  starvation  should  be  continued 
for  a  number  of  days,  for  if  a  small  amount  of  food  is  given  before  the 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  533 

patient  has  fully  recovered,  the  distension  of  the  stomach  is  likely  to 
reopen  the  bleeding  vessel,  and  the  more  often  this  occurs,  the  more  anemic 
the  patient  becomes.  With  increasing  anemia,  the  coagulability  of  the 
blood  decreases,  and  this  in  itself  increases  the  likelihood  of  subsequent 
hemorrhages. 

CHRONIC  ULCER  OF  THE  STOMACH. 

Clinical  observation  seems  to  show  that  only  a  small  proportion  of 
acute  ulcers  of  the  stomach  progress,  either  continuously  or  by  interruption, 
until  they  become  chronic.  The  ulcer,  after  its  first  appearance,  may  go 
on  causing  symptoms  until  the  condition  may  rightly  be  termed  chronic. 
These  symptoms  may  vary  in  severity  during  this  period,  or  they  may 
continue  at  the  same  degree  of  severity,  or  there  may  be  a  complete  inter- 
ruption of  the  symptoms  so  that  both  the  patient  and  the  physician  may 
reasonably  suppose  that  the  ulcer  is  permanently  healed.  The  recurrence 
may  be  brought  about  by  some  indiscretion  in  diet,  by  unfavorable  hygienic 
condition,  or  by  overwork.  A  rather  common  exciting  cause  is  indigestion 
from  overwork,  which  causes  a  general  neurotic  state. 

The  chief  symptoms  of  chronic  ulcer  of  the  stomach  are :  first,  pain ; 
second,  obstructon  to  the  passage  of  food;  third,  hemorrhage;  fourth, 
malnutrition. 

The  usual  location  of  pain,  as  before  said,  is  at  a  point  half  way  between 
the  ensiform  appendix  of  the  sternum  and  the  umbilicus.  This  pain  is 
increased  upon  pressure ;  it  is  usually  increased  upon  taking  certain  articles 
of  food.  If  the  ulcer  is  located  in  the  lesser  curvature  of  the  stomach, 
to  the  left  of  its  center,  the  pain  is  referred  to  a  point  a  little  below  the 
center  of  the  sternum,  and  pain  at  this  point  is  felt  if  pressure  is  made  over 
the  upper  portion  of  the  abdomen.  If  the  ulcer  is  located  in  the  pyloric 
end  of  the  stomach,  but  does  not  involve  the  pylorus,  the  pain  is  usually 
increased  soon  after  taking  food,  and  the  greatest  point  of  tenderness  is 
apt  to  be  in  mid-epigastrium.  If  the  ulcer  involves  the  pylorus  or  extends 
into  the  duodenal  side,  there  is  usually  a  very  clear-cut,  definite  train  of 
symptoms,  which  are  the  same  as  those  of  duodenal  ulcer.  Early  in  the 
history  of  these  cases  the  appetite  remains  good,  there  is  no  loss  of  weight 
and  the  taking  of  food  brings  immediate  relief  to  all  symptoms.  The 
burning  pain,  the  eructation  of  sour  gas,  return  in  from  one  to  four  hours 
after  eating.  Many  of  these  patients  suffer  from  nausea  and  vomiting, 
which  also  returns  with  the  other  symptoms.  As  a  rule  the  heartier  the  meal 
the  more  marked  and  prolonged  the  relief.  It  is  very  common  for  these 
patients  to  awaken  during  the  night  with  a  severe  burning  pain  in  the 
stomach,  which  is  relieved  by  taking  a  glass  of  milk  or  other  food.  Early 
in  the  disease  these  symptoms  are  periodic  and  alternate  with  complete 
freedom  of  symptoms.  Later  on  after  many  attacks  the  patients  have  the 
same  characteristic  symptoms  but  they  are  less  definite.  The  attacks  are 
more  severe  and  continue  for  a  longer  time ;  the  appetite  may  fail  or  the 
patient  may  be  afraid  to  eat  on  account  of  the  pain,  gas  and  sour  eructation ; 
food  and  drinks  give  relief,  but  the  time  of  relief  is  shortened.  Relief  may 
also  come  from  vomiting,  irrigation  and  alkalies,  but  the  pain  recurrs  when 
the  acid  contents  of  the  stomach  return. 

The  characteristic  point  is  the  time  the  symptoms  appear,  and  their 
regularity  after  meals,  and  the  relief  which  comes  from  taking  food,  or  by 
vomiting  or  irrigation. 


534  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

Later  when  complications  arise  the  symptoms  may  change.  Food  may 
not  give  relief  but  is  apt  to  increase  the  pain,  which  is  often  nearly  con- 
tinuous. In  these  chronic  cases  it  is  the  early  part  of  the  history  which  is 
most  apt  to  lead  us  to  a  correct  diagnosis. 

Dilatation. 

Dilatation  of  the  stomach  is  a  late  symptom  of  gastric  ulcer.  It  is 
caused  by  the  obstruction  which  the  ulcer  itself  offers  in  the  pyloric  channel, 
or  by  the  cicatricial  contraction  which  results  from  partial  or  complete 
healing  of  the  ulcer. 

Hyperacidity. 

In  chronic  ulcer  of  the  stomach  hyperacidity  is  usually  present,  and  in 
duodenal  ulcer  acids  are  practically  always  very  high.  It  has  frequently 
been  claimed  that  the  presence  or  absence  of  free  hydrochloric  acid  in  the 
stomach,  and  the  presence  of  lactic  acid,  can  be  used  in  making  a  differential 
diagnosis  between  chronic  ulcer  and  carcinoma  of  the  stomach.  This  method 
is  not  to  be  relied  upon  as  its  employment  is  apt  to  lead  to  serious  mistakes. 
Extensive  observations  by  different  investigators  have  proven  that  free 
hydrochloric  acid  is  absent  from  the  stomach  contents  in  a  large  proportion 
of  normal  stomachs  in  persons  over  sixty  years  of  age.  Again  in  early 
carcinoma  the  acids  are  apt  to  be  high  and  only  go>  down  after  there  is 
marked  stasis  of  the  stomach  contents  from  obstruction  during  the  later 
stages  of  the  carcinoma  of  the  stomach. 

Perforated  Gastric  or  Duodenal  Ulcer. 

A  perforation  may  take  place  in  either  the  acute  or  chronic  form  of 
gastric  and  duodenal  ulcers.  Formerly  it  was  thought  that  a  perforation  of 
a  duodenal  ulcer  was  extremely  rare.  There  is  no  doubt  but  that  in  the  past 
many  perforated  duodenal  ulcers  occurred  and  resulted  in  diffuse  septic 
peritonitis  and  the  appendix  was  blamed  for  the  peritonitis.  This  supposition 
seems  reasonable  because  recently  a  far  greater  percentage  of  perforated 
duodenal  ulcers  have  been  encountered  than  was  formerly  supposed  to  exist. 
Occasionally  in  both  the  duodenal  and  gastric  ulcers  the  perforation  occurs 
without  any  previous  symptoms,  but  usually  a  definite  ulcer  history  can  be 
elicited  previous  to  the  symptoms  of  perforation.  Then  the  patient  suffers 
from  a  very  severe  acute  attack  which  usually  follows  some  pronounced 
physical  exertion.  Occasionally  the  attack  comes  on  after  some  indiscretion 
in  diet,  and  only  rarely  does  it  occur  without  any  apparent  exciting  cause. 
The  patient  suffers  from  a  very  acute  pain  in  the  upper  portion  of  the 
abdomen  and  the  pain  is  usually  described  as  coming  on  with  a  feeling  as 
though  something  had  ruptured.  There  is  early  nausea  and  usually  vomiting 
of  stomach  contents,  which  may  or  may  not  be  mixed  with  blood.  The 
abdominal  muscles  immediately  become  tense  and  there  is  a  condition  of 
shock.  Physical  examination  elicits  a  rigid  condition  of  all  of  the  abdominal 
muscles,  and  especially  those  of  the  upper  half  of  the  abdomen.  There  is 
marked  tenderness  upon  pressure  in  epigastrium  and  usually,  but  not 
always,  an  absence  of  liver  dullness. 

The  pulse  becomes  rapid  and  thready.  Early  there  is  no  rise  of 
temperature,  but  this  comes  on  with  the  progress  of  the  peritoneal  infection. 
If  the  condition  is  not  diagnosed  and  relieved  early,  the  symptoms  become 
those  of  a  peritonitis. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  535 

Treatment  of  Perforated  Gastric  and  Duodenal  Ulcers. 

Immediate  operation  is  always  indicated  provided  the  patient  comes 
under  observation  during  the  first  twelve  hours  after  the  perforation  has 
taken  place.  Statistics  show  that  the  mortality  in  these  cases  is  about  twenty- 
eight  per  cent,  while  in  cases  which  come  under  observation  twenty-four 
hours  or  more  after  perforation  has  taken  place  is  more  than  three  times 
as  great.  In  these  latter  classes  the  method  of  treatment  must  depend  upon 
the  judgment  of  the  surgeon.  If  the  condition  present  indicates  that  the 
leakage  has  not  been  great,  or  the  probability  of  the  opening  being  closed  by 
a  plug  of  omentum  or  by  the  presence  of  other  adhesions,  it  may  be  wise  to 
place  the  patient  upon  exclusive  rectal  feeding  until  a  circumscribed  abscess 
has  been  formed,  which  abscess  may  then  be  drained. 

In  the  early  cases  the  operation  should  be  performed  immediately  and 
without  any  preliminary  preparation.  The  incision  should  be  free  and  in  the 
mid-line.  As  soon  as  the  abdomen  is  opened  an  immediate  search  for  the 
perforation  should  be  made.  This  should  be  carried  out  in  a  systematic 
manner  so  that  the  tissues  will  not  be  handled  any  more  than  necessary. 

As  soon  as  the  perforation  is  found  it  is  grasped  and  held  closed  tem- 
porarily by  an  assistant,  while  the  surgeon  carefully  sponges  all  of  the  soiled 
areas  to  remove  as  much  of  the  stomach  contents  as  possible,  great  care 
being  used  to  cause  little  or  no  traumatism  to  the  peritoneum.  The  remaining 
portion  is  now  shut  off  from  the  field  of  operation  by  the  placing  of  some 
large  gauze  pads  in  the  abdominal  cavity.  A  stomach  tube  is  now  introduced 
and  gastric  lavage  carried  out  until  the  water  returns  perfectly  clear.  The 
perforation  should  now  be  closed  and  in  doing  this  care  should  be  used 
so  that  the  stomach  will  be  left  free  from  any  deformity  which  may  later 
cause  an  obstruction. 

As  a  rule  the  hemorrhage  has  ceased  by  the  time  the  operation  is  per- 
formed so  it  is  not  necessary  to  give  any  attention  to  this  part  of  the 
condition. 

The  opening  in  the  stomach  is  sutured  by  placing  a  row  of  Council 
sutures,  covered  by  a  second  row  of  Lembert  stitches.  The  row  of  sutures 
should  be  placed  at  right-angles  to  the  long  axis  of  the  stomach  to  prevent 
a  narrowing  which  might  later  cause  an  obstruction. 

Thorough  drainage  should  be  established. 

If  there  has  been  an  extensive  extravasation  of  stomach  contents,  a 
second  incision  should  be  made  just  above  the  symphysis  pubis  and  a  drain 
carried  down  into  the  cul-de-sac,  while  the  upper  portion  of  abdominal 
cavity  should  be  drained  through  the  upper  angle  of  the  original  incision. 

If  the  perforation  has  taken  place  at  or  near  the  pylorus  one  may  expect 
a  certain  amount  of  obstruction  to  follow  and  it  may  become  necessary  to 
perform  a  gastro-cnterostoiny  for  relief  of  same. 

It  is  rarely  necessary  nor  wise  to  perform  a  gastro-enterostomy  at  the 
time  of  closing  an  acute  perforation  of  the  stomach,  because  the  additional 
time  and  manipulation  is  apt  to  increase  the  gravity  of  the  prognosis. 

Treatment  of  Chronic  Gastric  Ulcer. 

There  are  many  cases  in  which  a  permanent  cure  is  not  possible  although 
they  have  received  most  careful  dietetic,  hygienic  and  medicinal  treatment. 
In  any  given  case  the  sooner  this  fact  has  been  established  the  better,  in 
order  that  the  operation  may  be  performed  before  one  or  the  other  of  the 
various  unfortunate  complications  may  have  arisen. 


536  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

The  most  serious  complications  to  be  considered  are  (i)  perforation, 
.(2)  hemorrhage,  acute  or  chronic;   (3)   emaciation;   (4)  adhesion  to  sur- 
rounding structures;  (5)  the  implantation  of  carcinoma. 

Besides  these  serious  complications  which  are  apt  to  occur  a  number  of 
physiological  and  anatomical  changes  develop  quite  constantly. 
Secretion  of  Mucus. 

In  order  to  protect  the  ulcer  from  the  irritating  gastric  juice  a  large 
amount  of  mucus  is  secreted.  At  the  same  time  there  is  a  contraction  of 
the  muscles  in  the  region  of  the  pylorus  to  establish  a  condition  of  phys- 
iological rest.  Many  of  these  patients  do  very  well  if  placed  upon  an 
exclusive  liquid  diet,  because  with  this  neither  the  presence  of  mucus  nor 
the  contraction  of  the  muscles  does  any  harm,  especially  if  the  gastric  juice 
is  kept  alkaline  by  proper  remedies ;  and,  if  milk  is  given,  it  is  medicated  so 
that  it  will  not  form  coagula. 

It  is  quite  different  with  solid  food  as  on  the  one  hand  this  will 
be  rendered  much  more  indigestible  by  being  covered  with  mucus,  while  the 
obstruction  caused  by  the  contraction  of  the  muscles  in  the  pyloric  end  of 
the  stomach  interferes  with  the  passage  of  the  food  into  the  small  intestine. 
Hypertrophy  of  Gastric  Muscles. 

To  overcome  the  former  difficulty  a  great  amount  of  hydrochloric  acid 
is  secreted,  while  to  correct  the  latter  there  is  a  compensatory  hypertrophy 
of  the  muscles  of  the  stomach. 

Of  course  the  hyperacidity  of  the  gastric  juice  increases  the  irritation 
of  the  ulcer,  and  the  muscle  hypertrophy  increases  the  traumatism,  con- 
sequently both  of  these  changes  are  likely  to  do  much  more  harm  than  good. 

If  the  ulcer  has  healed,  in  the  meantime,  all  may  still  be  well,  but  if  this 
has  not  occurred,  conditions  are  practically  certain  to  go  from  bad  to  worse 
until  relieved  by  surgical  intervention.  Meanwhile,  the  following  changes 
may  have  occurred  in  the  ulcer  itself;  it  may  have  encroached  upon  some 
blood  vessel  of  considerable  size  causing  dangerous  hemorrhage ;  it  may 
have  advanced  to  a  point  dangerously  near  to  perforation,  causing  adhesions 
to  other  organs,  or  a  perforation  into  one  of  these  organs,  the  pancreas,  liver, 
spleen,  omentum  or  the  duodenum,  or  into  the  abdominal  wall  may  have 
taken  place.  We  have  personally  encountered  all  of  these  conditions. 

The  ulcer  may  have  perforated  into  the  free  abdominal  cavity,  or  a 
carcinoma  may  have  been  implanted  upon  the  ulcer. 

The  most  common  course,  however,  results  in  an  obstruction  at  the 
pyloric  end  which  may  be  clue  to  an  extensive  induration  at  the  base  of  the 
ulcer,  to  a  cicatricial  contraction  as  a  result  of  the  healing  of  the  ulcer, 
or  to  a  spasmodic  contraction  of  the  pyloric  sphincter.  This  obstruction, 
as  has  been  stated  above,  will  be  overcome  for  a  time  by  the  compensatory 
hypertrophy  of  the  muscles  of  the  stomach  but  if  not  relieved  this  will 
invariably  be  followed  by  an  exhaustion  of  the  muscles  and  a  consequent 
gastric  dilatation.  This  dilatation  may  be  moderate  in  degree  or  it  may  be 
excessive.  We  have  seen  the  lower  edge  of  the  stomach  resting  in  the  pelvis 
of  the  patient. 

In  the  presence  of  marked  dilatation,  there  always  remain  portions  of 
food  in  the  stomach  and  this  residual  food  invariably  decomposes  so  that 
the  patient  is  forced  to  absorb  products  of  decomposition  instead  of  product? 
of  normal  digestion.  All  fresh  food  placed  in  the  stomach  is  at  once 
contaminated  by  the  decomposing  fluid.  This  condition  accounts  for  the 


PLATE  LXXII. 

Mayo-Moynihan  method  of  gastro-enternstomy,  showing  lowest  portion  of  pos- 
terior wall  of  stomach  brought  through  a  tear  in  the  mesentery  of  the  transverse 
colon,  and  the  points  on  the  stomach  and  jejunum  selected  for  the  anastomosis. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  541 

emaciation  or  cachexia  which  is  invariably  present  in  advanced  cases  of  this 
kind.  The  marked  improvement  often  following  the  systematic  use  of 
gastric  lavage  is  easily  explained  when  one  takes  into  consideration  the 
above  conditions. 

It  is,  of  course,  best  not  to  delay  until  this  extreme  development  before 
relieving  the  patient  through  surgical  means. 

Relief  in  these  cases  must  come  by  supplying  drainage.  It  has  been 
shown  by  a  very  large  clinical  experience  that  with  efficient  drainage  of  the 
stomach,  by  way  of  a  properly  executed  gastro-enterostomy,  better  conditions 
may  be  established  for  the  patient  than  by  any  other  present  method  of 
treatment. 

Such  results  will  vary  not  only  with  the  skill  of  the  operator  but,  also,  as 
regards  their  permanency,  with  the  care  with  which  these  patients  avoid 
hygienic  and  dietetic  abuses  after  recovering  from  the  operation. 

The  treatment  of  duodenal  ulcer  is  the  same  as  that  for  gastric  ulcer. 

GASTRO-ENTEROSTOMY. 

Gastro-enterostomy  may  be  performed  for  the  following  conditions : 
First,  for  relief  of  obstruction  of  the  pylorus;  second,  for  the  purpose  of 
relieving  the  irritation  due  to  the  passage  of  food  over  an  ulcer  in  the  pyloric 
end  of  the  stomach  or  duodenum ;  third,  for  drainage  of  a  greatly  distorted 
stomach ;  fourth,  drainage  of  a  stomach  containing  an  inoperable  carcinoma ; 
fifth,  for  establishing  a  communication  between  the  remnant  of  a  stomach 
and  the  intestine  after  the  pyloric  end  of  the  stomach  has  been  removed. 
Preparatory  Treatment. 

In  many  of  these  cases,  not  sufficiently  strong  to  bear  an  operation  well, 
because  of  their  impaired  nutrition,  together  with  the  anemia  caused  by  the 
loss  of  blood,  it- is  wise  to  treat  the  patient  for  a  time  before  undertaking  the 
operation.  It  is  well  in  these  cases  to  remove  all  decomposing  substances 
from  the  stomach  and  intestines  by  the  administration  of  castor  oil,  given 
in  the  manner  described  before  in  the  foam  of  beer  or  extract  of  malt,  in 
doses  of  two  ounces.  We  have  used  this  in  many  cases  and  have  never  seen 
the  slightest  harm  result  from  it,  but  have,  on  the  contrary,  constantly  ob- 
served great  benefit.  Then  it  is  well  to  permit  the  stomach  to  rest  completely 
for  one  or  two  weeks,  or  even  longer,  and  to  administer  nourishment  by 
nutrient  enemata.  Mild  saline  laxatives  may  be  given  by  mouth  because  this 
will  facilitate  the  healing  of  the  gastric  ulcer  and  will  at  the  same  time 
prevent  constipation.  Pure  olive  oil,  given  at  bedtime  in  doses  of  two 
ounces,  seems  to  aid  in  building  up  the  patient  and  at  the  same  time  leave  the 
ulcerated  stomach  without  giving  rise  to  any  irritation. 

If  there  are  no  acute  symptoms  it  is  wrell  to  cocainize  the  pharynx  well 
by  spraying  it  with  a  four  per  cent  solution  of  cocain.  The  patient  should 
be  permitted  to  swallow  a  little  of  this  in  order  to  anesthetize  the  esophagus. 
After  waiting  about  four  minutes,  in  order  to  give  the  cocain  an  opportunity 
to  take  effect,  irrigate  the  stomach  thoroughly  with  normal  salt  solution. 

If  there  are  any  symptoms  of  acute  inflammatory  disturbance  in  the 
lining  of  the  stomach  it  is  better  to  avoid  gastric  lavage,  as  this  might  give 
rise  to  hemorrhage  from  an  ulcer. 

It  is  best  not  to  inflate  a  stomach  with  gas  so  long  as  one  suspects  the 
presence  of  an  ulcer,  for  fear  of  perforation,  but  this  is  necessary  in  order 
to  determine  positively  the  extent  of  gastric  dilatation.  It  is  safest  to  insert 


542  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

a  stomach  tube  for  the  purpose  of  distending  the  stomach  with  gas,  and  to 
attach  it  to  an  ordinary  rubber  bulb  with  which  air  can  be  pumped  into  the 
stomach  slowly  and  consequently  safely.  After  the  degree  of  dilatation  has 
been  determined  the  gas  may  be  permitted  to  escape  through  the  tube. 

If  the  patient  is  in  fair  physical  condition  the  only  preparatory  treatment 
necessary  is  the  administration  of  two  ounces  of  castor  oil  the  day  before 
the  operation  and  a  gastric  lavage  the  evening  before,  and  again  on  the 
morning  of  the  operation. 

Incision. 

An  incision  about  four  centimeters  to  the  right  of  the  median  line  will 
be  found  most  satisfactory  in  the  majority  of  cases,  so  that  the  stomach, 
duodenum,  gall  bladder  and  appendix,  can  all  be  carefully  inspected.  All  of 
these  organs  should  not  only  be  palpated,  but  should  be  inspected  as  well, 
before  it  is  definitely  decided  what  procedure  shall  be  carried  out  in  any 
particular  case. 

During  the  past  three  years  the  authors  have  used  the  Moynihan-Mayo 
method  of  gastro-enterostomy,  which  has  proved  very  satisfactory  indeed. 
This  operation  contains  the  important  elements  reasonably  to  be  expected  in 
a  gastro-enterostomy.  It  is  simple.  It  places  the  opening  in  the  lowest 
part  of  the  stomach.  It  provides  an  opening  large  enough  to  prevent 
secondary  obstruction  from  contraction.  It  establishes  an  immediate  com- 
munication between  the  stomach  and  the  intestine.  It  leaves  the  jejunum 
practically  in  its  normal  position  and  without  any  angulation.  It  leaves  no 
loop  to  cause  intestinal  obstruction.  It  prevents  the  possibility  of  hemorrh- 
age either  during  or  after  the  operation.  It  prevents  soiling  of  the 
peritoneal  cavity  by  intestinal  or  stomach  contents  during  the  operation. 

The  first  step  of  the  operation  is  to  select  a  point  in  the  stomach  wall 
for  the  anastomosis.  This  point  should  be  made  in  healthy  tissue  a  con- 
siderable distance  from  the  diseased  area,  if  possible. 

It  is  wise  to  choose  the  most  dependent  portion  of  the  stomach  for 
this  purpose,  because  this  will  secure  a  more  perfect  drainage  than  could  be 
accomplished  in  any  other  way,  the  walls  of  the  stomach  forming  a  kind 
of  funnel  in  which  all  of  the  sides  slope  down  to  the  point  of  anastomosis. 

Mayo  has  pointed  out  the  fact  that  by  doing  this,  it  is  possible,  in 
almost  every  case,  to  prevent  regurgitant  vomiting  after  gastro-enterostomy. 

The  transverse  colon  is  brought  up  out  of  the  wound  and  its  mesentery 
placed  taut,  as  in  Plate  LXXII,  and  an  opening  is  torn  in  the  mesocolon 
at  a  non-vascular  point  opposite  the  crossing  of  the  jejunum.  The  posterior 
wall  of  the  stomach  is  brought  out  through  this  opening  and  the  lowest 
point  in  the  greater  curvature  of  the  stomach  is  grasped  bv  a  pair  of  tena- 
culum  forceps,  which  would  be  at  the  point  (a)  in  I 'late  LXXII.  A  second 
pair  of  forceps  should  be  placed  about  8  cm.  from  the  first  one  in  a  direction 
downwards  and  to  the  right,  as  at  (b)  in  I 'late  LXXI1.  This  makes  the 
opening  in  the  stomach  in  normal  direction  of  the  jejunum  after  it  passes 
through  the  mesocolon.  which  is  from  right  downwards  to  the  left  in  eighty 
per  cent  of  cases,  according  to  Lewis.  In  the  other  twenty  per  cent  it  is 
from  the  left  downwards  to  the  right.  In  these  cases  the  opening  should  be 
from  left  to  right  in  the  stomach.  As  soon  as  the  two  forceps,  marking  the 
location  and  direction  of  the  opening  in  the  stomach,  have  been  applied, 
the  stomach  wall  lying  between  these  two  forceps  should  be  grasped 
by  a  pair  of  stomach  forceps,  the  blades  of  which  should  be  protected 


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SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  C.<< 

or-- 

by  rubber  tubing,  as  shown  in  Plate  LXXIII.  Care  should  be  used 
to  have  a  sufficient  amount  of  the  stomach  wall  project  beyond  the  blades  of 
the  forceps  to  prevent  tension  during-  suturing.  The  jejunum  is  next  picked 
up,  which  is  found  by  passing  the  hand  down  along  the  mesocolon  to  a  point 
just  to  the  left  of  the  spine.  The  jejunum  is  now  grasped  on  its  convex 
surface  two  to  five  centimeters  distant  from  the  point  where  the  intestine 
passes  through  the  transverse  mesocolon  at  point  (I/)  Plate  LXXIII,  and  a 
second  8  cm.  distant  at  point  (a').  This  portion  of  the  intestinal  wall  is 
grasped  by  another  pair  of  long-bladed  forceps  in  the  same  manner  as  the 
stomach  wall,  and  the  two  forceps  are  placed  side  by  side,  as  shown  in  Plate 
LXXIII.  Gauze  pads  are  now  placed  about  the  forceps  protecting  all  of  the 
tissues  except  the  small  portion  of  the  stomach  and  duodenum  within  the 
grasp  of  the  forceps.  The  next  step  consists  in  placing  a  row  of  Lembert 
stitches  uniting  the  stomach  and  jejunum  for  a  distance  of  about  six  centi- 
meters, as  in  Plate  LXXIV.  Fine  silk  or  linen  thread  is  usually  used  in 
making  this  stitch.  An  incision  is  now  made  into  the  stomach  about  one- 
fourth  of  a  centimeter  distant  from  the  suture  line,  then  a  similar  one  into 
the  jejunum.  As  these  incisions  are  made  any  stomach  and  intestinal  con- 
tents should  be  carefully  sponged  away  to  avoid  soiling  any  of  the  tissues. 
The  openings  just  made  should  be  about  five  centimeters  in  length,  which  is 
one  centimeter  shorter  than  the  first  suture  line.  Plate  LXXV. 

A  second  row  of  sutures  consisting  of  a  running  chromicized  catgut 
stitch  is  placed  just  in  front  of  the  Lembert  stitch,  which  passes  through  all  of 
the  coats  of  the  stomach  and  intestine  (Plate  LXXVT  ).  This  stitch  controls 
the  hemorrhage  and  approximates  the  cut  edges  behind,  completing  the 
posterior  suturing.  This  same  stitch  is  now  continued  forward  approxi- 
mating the  edges  anteriorly,  folding  the  edge  of  the  mucous  membrane  inside, 
passing  through  all  of  the  stomach  and  intestinal  coats  to  prevent  hem- 
orrhage (Plate  LXXVII).  The  first  Lembert  stitch  is  now  continued  forward 
approximating  the  peritoneal  surfaces  anteriorly  (Plate  LXXVI II).  This 
stitch  completes  the  anastomosis. 

The  opening  in  the  transverse  mesocolon  should  now  be  closed  by  sutur- 
ing its  edges  along  the  line  of  anastomosis.  This  may  be  attached  on  the 
jejunal  side,  or  the  stomach,  or  to  both,  directly  over  the  line  of  suture.  In 
doing  this  care  should  be  used  to  see  that  the  opening  in  the  mesocolon  is 
large  enough  so  there  can  be  no  constriction  which  might  cause  an  obstruc- 
tion by  kinking  the  jejunum. 

After-treatment  of  Gastro-enterostomy. 

As  soon  as  the  patient  recovers  from  the  anesthetic  he  should  be  placed 
on  a  head  rest  in  a  semi-sitting  posture.  This  position  favors  drainage  of 
mucus  into  the  intestine,  which  may  accumulate  in  the  stomach  after  the 
operation,  and  also  favors  expulsion  of  gas  through  the  esophagus.  If  the 
patient  suffers  from  nausea  or  vomiting,  gastric  lavage  should  be  used.  In 
doing  this  care  should  be  employed  not  to  distend  the  stomach.  Not  more 
than  half  a  pint  of  water  should  be  allowed  to  run  into  the  stomach  at  one 
time.  If  the  vomiting  recurs,  the  lavage  should  be  repeated. 

Occasionally,  the  patient  suffers  from  acute  dilatation  of  the  stomach. 
This  condition  may  come  on  suddenly  and  is  characterized  by  a  sense  of  full- 
ness and  distension  of  the  upper  portion  of  the  abdomen.  The  breathing 
becomes  labored,  the  heart  very  rapid  and  the  picture  is  one  of  a  very  alarm- 
ing state.  The  condition  can  easily  be  relieved  by  passing  a  stomach  tube. 
Enormous  quantities  of  gas  will  escape  through  the  tube  and  the  patient  will 


556  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

obtain  immediate  relief.    The  pulse  and  breathing  soon  become  normal  and 
the  patient  again  proceeds  in  a  satisfactory  manner. 

Feeding. 

If  the  patient  is  not  greatly  reduced,  it  is  best  to  feed  per  rectum  for 
three  or  four  days,  and  then  allow  broth,  gruel,  or  buttermilk,  or  some  of 
the  commercial  concentrated  liquid  foods.  In  anemic  patients  the  authors 
have  frequently  allowed  liquid  food  on  the  second  day  with  good  results, 
and  at  the  same  time  administered  salt  solution  and  some  predigested  food 
per  rectum.  The  diet  should  be  carefully  regulated  for  several  months  after 
the  operation  so  that  the  mechanical  and  chemical  functions  of  the  stomach 
may  become  as  near  normal  as  possible  after  the  changed  anatomical  rela- 
tions following  the  operation. 

EXCISION   OF   GASTRIC    ULCER. 
Technique. 

It  has  at  times  seemed  wise  to  remove  a  gastric  ulcer  radically  by  ex- 
cising it  entire,  and  uniting  the  edges  of  the  wound  in  the  stomach.  This  is 
done  especially  because  it  has  been  long  known  that  gastric  ulcers  are  a 
predisposing  cause  to  the  development  of  carcinoma.  Usually  these  ulcers 
do  not  persist  unless  there  is  an  obstruction  to  the  passage  of  the  food 
through  the  pylorus,  and  if  this  condition  exists  the  excision  of  an  ulcer 
would  hardly  result  in  a  permanent  cure.  Moreover,  the  establishment  of 
free  drainage  of  the  stomach  by  means  of  a  gastro-enterostomy  would  re- 
sult in  the  healing  of  such  an  ulcer.  However,  there  is  a  class  of  ulcers 
which  stand  on  the  border  line  of  malignant  growths,  and  in  this  class  an 
excision  of  the  ulcer  and  surrounding  tissues  is  certainly  indicated.  This 
can  be  done  most  safely  by  lifting  up  the  stomach  and  making  an  incision 
around  the  ulcer,  first  through  the  serous  and  muscular  coats,  then  grasping 
all  of  the  vessels  with  hemostatic  forceps  and  ligating  them  with  fine  catgut, 
then  lifting  the  wall  of  the  stomach  so  as  to  have  the  wound  extend  at  right 
angles  with  the  long  axis  of  the  stomach.  The  mucous  membrane  may  now 
be  sutured  without  first  cutting  it,  or  it  may  be  cut  and  then  sutured  with  a 
continuous  catgut  or  silk  suture,  the  first  row  grasping  only  the  muscular 
rind  mucous  layers.  Over  this  a  continuous  Lembert  suture  is  applied.  This 
suture  grasps  all  of  the  layers  down  to  the  mucous  membrane,  but  not 
through  it.  By  applying  this  row  of  sutures  transversely  to  the  axis  of  the 
stomach  one  avoids  the  tendency  of  narrowing  the  lumen  of  the  pylorus  in 
case  the  ulcer  is  near  the  pyloric  end. 

The  excision  of  an  ulcer  should  not  prevent  the  surgeon  from  making 
a  gastro-enterostomy  if  this  is  otherwise  indicated,  but  a  portion  of  the 
stomach  must  be  selected  sufficiently  distant  from  the  location  of  the  ulcer 
to  insure  satisfactory  healing.  Of  course,  the  same  precautions  should  be 
taken  in  making  gastroenterostomies  in  these  cases  as  in  all  others. 

In  crises  in  which  a  chronic  ulcer  of  the  stomach  co-exists  with  a  stenosis 
of  the  pylorus  sufficiently  small  to  indicate  a  gastro-enterostomy,  it  is  doubt- 
ful whether  an  excision  of  the  ulcer  is  ever  indicated,  because  the  gastro- 
enterostomy  will  be  followed  by  a  perfect  drainage  of  the  stomach,  and 
this  by  the  permanent  healing  of  the  gastric  ulcer. 

Rodman  has  suggested  that  in  ulcer  of  the  pyloric  end  of  the  stomach 
the  pyloric  end  be  excised  entirely  to  a  sufficient  distance  beyond  the  ulcer  to 
include  what  he  calls  the  ulcer-bearing  area,  and  then  to  make  a  gastro-en- 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  557 

terostomy  similar  to  that  which  has  been  described.  Aside  from  the  fact 
that  this  method  removes  the  ulcer  radically  it  has  the  further  advantage  of 
removing  the  portion  of  the  stomach  in  which  carcinoma  is  most  likely  to 
occur  secondarily  to  the  existence  of  an  ulcer. 

GASTRO-ENTEROSTOMY  AND   ENTERO-ENTEROSTOMY  WITH  THE 
McGRAW    ELASTIC    LIGATURE. 

This  method  has  been  found  very  satisfactory  in  cases  in  which  there 
is  not  a  complete  obstruction  of  the  pylorus.  The  elastic  ligature  does  not 
cut  its  way  out  for  two  to  four  days,  so  there  is  no  drainage  from  this 
source  during  that  time.  If  the  obstruction  of  the  pylorus  is  complete,  there 
is  apt  to  be  an  accumulation  of  fluid  in  the  viscus  which  cannot  pass  on  until 
the  elastic  cord  has  established  a  communication  between  the  stomach  and  the 
jejunum. 

The  immediate  results  have  been  characterized  by  an  absence  of  shock 
and  discomfort  following  the  operation  and  there  has  been  no  regurgitant 
vomiting,  vicious  circle  after  gastro-enterostomy,  the  anterior  operation  hav- 
ing been  employed  invariably  and  the  lowest  point  having  been  chosen,  the 
anastomosis  being  made  directly  above  the  gastro-epiploic  artery. 

In  gastro-enterostomy  the  following  steps  are  taken :     The  abdomen  is 
opened  in  the  usual  manner. 
Technique. 

The  transverse  colon  and  the  omentum  are  then  drawn  out  through 
the  incision  and  the  jejunum  is  located  a  little  to  the  left  of  the  median  line, 
just  where  it  passes  through  the  mesentery  of  the  colon.  By  lifting  up  the 
colon  one  can  always  easily  locate  this  intestine. 

It  is  preferable  to  make  a  posterior  gastro-enterostomy  through  a  tear 
in  the  transverse  mesocolon,  the  beginning  of  the  jejunum  being  united  to 
the  lowest  portion  of  the  stomach.  The  points  of  anastomosis  on  the  stomach 
and  the  jejunum  are  selected  just  the  same  as  described  in  the  Mayo-Moyni- 
han  operation  previously  mentioned.  The  jejunum  and  stomach  are  sutured 
together  wtih  a  running  Lembert  stitch  for  a  distance  of  seven  centimeters. 

A  long  needle  armed  with  a  McGraw  elastic  ligature  is  then  passed  into 
the  lumen  of  the  intestine,  as  in  Plate  LXXXI,  so  that  its  points  of  entrance 
and  exit  are  one-half  cm.  within  the  line  of  sutures  at  each  end.  The  point 
of  the  needle  is  grasped  with  forceps,  then  the  elastic  ligature  is  stretched  in 
order  to  decrease  its  caliber  so  that  it  will  thoroughly  fill  the  needle  holes  in 
the  intestine  when  it  is  relaxed  after  being  drawn  through.  The  same 
step  is  reversed  in  the  stomach.  A  strong  silk  ligature  is  then  placed  be- 
tween the  two  free  ends  of  the  elastic  ligature,  which  are  then  tied  in  a  half 
knot,  as  in  Plate  LXXXI1.  While  these  ends  are  drawn  very  tightly  the  silk 
ligature  is  tied  down  upon  them  where  they  are  crossed.  It  is  well  to  tie 
a  triple  knot  in  the  silk  ligature  to  insure  against  slipping.  When  the  elastic 
ligature  is  relaxed  it  forms  a  little  enlargement  beyond  the  ligature  on  each 
side.  The  ends  are  cut  two  mm.  beyond  the  silk  ligature.  Then  the  con- 
tinuous silk  suture  is  completed  in  front  of  the  elastic  ligature  so  that  the 
latter  is  completely  buried ;  it  is  important  to  apply  this  suture  accurately  in 
order  to  prevent  any  leakage  when  the  elastic  ligature  begins  to  cut  its  way 
through. 

The  accompanying  illustrations  are  taken  directly  from  Dr.  McGraw's 


558  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

original  drawings.  They  represent  an  enterostomy,  but  the  principle  is  pre- 
cisely the  same  and  it  is  not  difficult  to  imagine  the  operation  changed  to  a 
gastro-enterostomy. 

In  order  to  avoid  error  in  performing  this  operation  it  may  be  well  to 
recapitulate  the  steps : 

1.  A  round  rubber  cord  2  mm.  in  diameter,  made  of  the  best  material 
should  be  used. 

2.  A  posterior  row  of  Lembert  sutures  is  applied. 

3.  A  long,  straight  needle  armed  with  the  rubber  ligature  is  passed 
into  the  lumen  of  the  intestine  and  out  again  at  the  desired  distance,  from 
5  to  10  cm.  away  from  the  point  of  introduction. 

4.  While  an  assistant  holds   the   intestine  the   surgeon   stretches   the 
rubber  in  the  needle  and  when  quite  thin  draws  it  rapidly  through  the  in- 
testine. 

5.  The  same  step  is  repeated  through  the  stomach. 

6.  A  strong  silk  ligature  is  placed  across  and  underneath  the  rubber 
ligature  between  the  latter  and  the  point  where  the  stomach  and  intestine 
come  together. 

7.  A   single  tie   is   made   in  the   rubber  ligature  after  the   latter  has 
been  drawn  very  tightly. 

8.  The  silk  ligature  is  passed  around  the  ends  of  the  rubber  ligature 
where  they  cross,  and  tied  securely  three  times. 

9.  The  ends  of  the  latter  are  released  and  cut  off,  being  held  by  the  silk 
ligature. 

10.  The  Lembert  suture  is  continued  around  in  front  until  the  point 
of  its  beginning  is  reached,  where  it  will  be  tied. 

11.  Care  must  be  exercised  to  prevent  tying  the  rubber  ligature  too  far 
backward  and  thus  getting  behind  the  posterior  row  of  Lembert  sutures. 

We  are  thus  explicit  in  describing  the  steps  of  this  operation  because 
we  find  that  only  those  who  are  thoroughly  familiar  with  the  method  have 
used  it,  and  apparently  all  with  great  satisfaction. 

CARCINOMA  OF  THE  STOMACH. 

Importance  of  Early  Diagnosis. 

The  surgical  treatment  of  cancer  of  the  stomach  has  received  a  great 
deal  of  attention  during  the  past  few  years.  The  technique  of  resection  of 
the  stomach  for  carcinoma  has  reached  the  same  degree  of  perfection  as  that 
connected  with  the  surgical  treatment  of  other  abdominal  conditions,  and 
the  percentage  of  five-year  cures,  especially  in  early  cases,  compares  very 
favorably  with  the  results  in  surgical  treatment  of  cancer  in  other  portions  of 
the  body,  as  for  instance  cancer  of  breast  and  uterus.  The  important  point 
in  the  surgical  treatment  of  carcinoma  of  the  stomach  is  to  be  able  to  make 
an  early  diagnosis.  As  soon  as  the  diagnosis  is  made,  or  it  is  even  strongly 
suspected  to  be  a  case  of  carcinoma  of  the  stomach,  the  person  becomes  a 
surgical  patient  and  should  be  subjected  to  at  least  an  exploratory  incision. 

Typical  Case. 

The  patient  is  a  married  woman,  thirty-five  years  of  age,  giving  the 
following  history :  Her  family  history  is  negative.  She  suffered  from 
measles  as  a  child,  menstruated  at  seventeen,  regularly,  but  painful,  before 
the  time  of  her  marriage  at  the  age  of  twenty-eight.  One  year  later  she  had 


PLATE  LXXX. 

EXTEROSTOMY  WITH   McGRAW   ELASTIC  LIGATURE. 

The  primary  Lembert  suture  in  place. 

(From  Dr.  H.  O.  Walker's  original  drawing  of  Prof.  Theodor  McGraw's  opera- 
tion.) 


PLATE  LXXXI. 

EXTEROSTO.MV   WITH    McGRAW    ELASTIC   LlGATURE. 

The  primary  Lembert  suture  in  place.     The  elastic  ligature  .has  been  inserted 
but  not  tied. 

(From  Dr.  H.  O.  Walker's  original  drawings  of  Prof.  Theodor  McGraw's  opera- 
tion. ) 


PLATE  LXXXII. 
ENTEROSTOMY  WITH  McGRAW  ELASTIC  LIGATURE. 

Showing  posterior  Lembert   suture,  elastic   ligature  in  place  with   first   loop 
ready  to  tie. 

(From  Dr.  H.  O.  \\"alker's  original  drawings  of  Prof.  Theodor  McGraw's  opera- 
tion.) 


PLATE  LXXXIIT. 
ENTEROSTOMY  WITH  McGRAw  ELASTIC  LIGATURE. 

The  primary  Lembert  suture  in  place.     The  elastic  ligature  has  been  tied  but 
the  ends  have  not  yet  been  cut  short.     The  silk  ligature  securing  the  tied  ends  of 
the  elastic  ligature  has  been  tied  but  the  ends  have  not  been  cut  short. 
(From  Dr.  H.  O.  Walker's  original  drawings  of  Prof.  Theodor  McGraw's  opera- 
tion.) 


PLATE  LXXXIV. 
ENTEROSTOMY  WITH  McGRAW  ELASTIC  LIGATURE. 

Operation  Completed. 

(From  Dr.  II.  O.  Walker's  original  drawings  of  Prof.  Theodor  McGraw's  opera- 
tion.) 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  569 

a  miscarriage,  but  has  otherwise  been  in  good  health.  Five  months  ago, 
patient  began  to  suffer  from  acid  stomach  and  from  the  presence  of  a  feeling 
of  fullness  after  eating,  accompanied  by  eructations  of  gas.  She  has  also 
suffered  severely  from  constipation.  For  the  past  two  months  she  has 
vomited,  usually  after  taking  solid  food,  occasionally,  however,  she  would 
retain  any  kind  of  food  in  her  stomach  for  two  or  three  days  and  then  vomit 
all  that  she  had  taken  during  this  period  of  time.  She  has  not  suffered  any 
pain  and  her  temperature  has  been  normal.  She  has  occasionally  been  slight- 
ly jaundiced.  The  patient  has  never  been  very  well  nourished. 

Present  Condition. 

The  patient  is  quite  emaciated,  being  fifteen  pounds  below  her  usual 
weight ;  her  tongue  is  coated  and  she  is  very  hungry ;  her  bowels  are  consti- 
pated. Cathartics  give  rise  to  nausea.  Temperature  is  98°  F.,  the  pulse  86, 
regular  and  fairly  strong.  Heart,  lungs  and  kidneys  are  normal.  The  ab- 
domen is  distended,  but  not  tender  upon  pressure.  There  is  no  free  fluid  in 
the  peritoneal  cavity.  The  stomach  is  prolapsed  and  distended,  the  lower 
border  extends  two  inches  below  the  umbilicus.  Succussion  sounds  are 
marked  upon  shaking  the  abdomen.  A  hard,  elliptical  body,  movable  with 
respiration  can  be  felt  in  the  right  hypochondriac  region.  There  is  a  tym- 
panitic  space  between  this  mass  and  the  costal  arch.  The  mass  is  movable  in 
every  direction. 

Diagnosis. 

This  history  would  indicate  beyond  a  doubt  that  there  exists  in  this 
case  an  obstruction  of  the  pyloric  end  of  the  stomach.  This  may  be  due  to 
the  presence  of  a  malignant  growth  corresponding  to  the  tumor,  which  can 
easily  be  demonstrated,  or  it  may  be  due  to  a  non-malignant  stricture  of  the 
pylorus,  or  to  a  short  bend  in  this  part  of  the  alimentary  canal.  The  tumor 
is  farther  to  the  right  than  we  usually  find  a  carcinoma  of  the  pylorus  and 
it  might  readily  be  a  distended  gall  bladder  or  even  a  tumor  of  this  organ, 
or  it  might  be  a  movable  kidney  containing  a  small  tumor.  The  youth  of  the 
patient  might  be  considered  an  argument  against  the  diagnosis  of  carcinoma 
of  the  pylorus. 

Notwithstanding  these  facts,  there  can  scarcely  be  a  doubt  but  that  this 
patient  is  suffering  from  the  presence  of  a  carcinoma  obstructing  the  pylorus, 
because  the  history  and  the  findings  upon  physical  examination — hypera- 
cidity, pain,  hemorrhage,  dilatation,  emaciation,  and  tumor — are  very  char- 
acteristic in  this  case. 
Indications  for  Operation. 

Judging  from  the  size  of  the  tumor  and  the  amount  of  obstruction 
present,  it  is  not  at  all  likely  that  an  operation  will  result  in  the  removal  of 
the  malignant  growth,  or  in  case  a  removal  is  accomplished  it  is  not  at  all 
probable  that  this  will  result  in  a  radical  cure.  Consequently  the  best  that 
can  be  expected  from  an  operation  is  simply  a  certain  degree  of  temporary 
relief.  This  relief  will  consist  in  the  establishment  of  a  free  communication 
between  the  stomach  and  the  small  intestine.  As  a  result  of  this  the  nausea, 
vomiting  and  pain  will  rapidly  disappear,  the  nutrition  will  improve  and  the 
patient  will  no  longer  absorb  decomposition  products  from  the  stomach.  Her 
cachexia  will  consequently  disappear,  she  will  gain  in  weight  and  strength 
and  will  imagine  herself  quite  well  for  a  time. 

Sooner  or  later  the  carcinoma  will  have  involved  so  great  a  portion  of 


570  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

the  stomach  and  the  surrounding-  organs  that  she  will  succumb  to  the  disease, 
but  it  may  be  a  considerable  time  before  this  is  to  be  expected. 

Preparatory  Treatment. 

Gastric  lavage  will  be  performed  night  and  morning  for  one  or  two 
days  until  the  stomach  contents  no  longer  have  an  offensive  odor.  The 
morning  of  the  day  before  the  operation  two  ounces  of  castor  oil  will  be 
introduced  through  the  stomach  tube,  after  the  gastric  lavage  has  been  com- 
pleted. In  the  meantime  some  aseptic  predigested  food  will  be  given  every 
three  hours. 

Should  the  oil  not  produce  a  very  free  evacuation  of  the  bowels,  the  same 
dose  will  be  given  in  the  same  manner  every  twelve  hours  until  the  desired 
effect  has  been  accomplished.  If  the  oil  is  not  retained  in  the  stomach  free 
evacuation  of  the  bowels  will  be  accomplished  if  possible  by  means  of 
enemata.  On  the  morning  before  the  operation  the  stomach  will  again  be 
thoroughly  cleansed  by  means  of  gastric  lavage. 

Technique. 

The  incision  is  made  as  in  the  previous  case.  We  find  as  we  had  ex- 
pected, an  extensive  involvement  of  the  entire  pylorus  with  the  tumor  ex- 
tending well  up  on  the  lesser  curvature.  The  lymph  glands  to  a  considerable 
distance,  especially  behind  the  pylorus  and  along  the  lesser  and  greater 
curvature  of  the  stomach,  are  involved.  It  seems  plain  that  the  complete 
removal  of  these  glands,  together  with  the  tumor,  is  not  possible,  and  a  par- 
tial removal  would  only  serve  to  excite  a  more  rapid  growth,  consequently 
no  benefit  could  come  from  an  attempt  at  a  radical  operation  and  it  would 
not  be  wise  to  make  the  effort. 

The  healthy  portion  of  the  stomach  is  greatly  dilated  on  account  of  the 
almost  complete  closure  of  the  pyloric  opening.  The  greater  curvature  ex- 
tends more  than  two  inches  below  the  umbilicus.  The  operation  from  which 
the  greatest  amount  of  benefit  will  be  derived  is  a  simple  gastro-enterostomy. 

In  planning-  a  gastro-enterostomy  for  drainage  in  carcinoma  of  the 
stomach,  the  opening  should  be  chosen  at  a  point  quite  distant  from  the  car- 
cinoma. In  the  majority  of  cases  an  anterior  gastro-enterostomy  answers 
this  purpose  better  than  a  posterior.  The  authors  frequently  use  the 
Murphy  button  for  making  the  anastomosis,  and  it  will  be  used  in  this  case. 

The  jejunum  is  now  brought  up  out  of  the  abdominal  wound  and  a  point 
selected  twelve  to  sixteen  inches  from  the  mesentery  of  the  transverse  colon. 
A  small,  longitudinal  incision  is  made  through  the  peritoneum  and  muscular 
coat  down  to  the  mucous  coat,  then  a  purse-string  stitch  is  applied,  as  in  Plate 
LXXXV  a.  Then  the  mucous  membrane  is  cut  and  the  larger  segment  of 
a  Murphy  button  is  inserted  and  the  purse-string  suture  carefully  tied.  It 
is  important  to  apply  the  purse-string  suture  close  to  the  edge  of  the  wound 
in  the  intestine  in  order  to  prevent  the  tissues  being  drawn  together  in  ir- 
regular masses  around  the  button. 

By  drawing  a  small  bunch  of  moist  cotton  through  the  hole  in  the  button 
sufficiently  firm  to  prevent  leakage  much  annoyance  may  be  avoided,  because 
this  pledget  of  cotton  can  be  easily  removed  before  uniting  the  two  lobes  of 
the  button.  This  intestine  with  the  button  in  place  is  now  surrounded  with  a 
piece  of  moist  gauze  and  placed  to  one  side  while  the  other  half  of  the  but- 
ton is  inserted  into  the  stomach  in  very  much  the  same  way. 

We  have  selected  the  most  dependent  portion  of  the  greater  curvature 


PLATE  LXXXV. 

GASTRO-EXTEROSTOMY. 

Represents  anterior  gastro-enterostomy  with  the  sutures  in  place,  both  around 
the  incision  in  the  jejunum  and  the  one  at  the  lowest  point  in  the  stomach;  (a)  repre- 
sents the  proper  position  for  uniting  the  intestine  to  the  stomach;  (b)  represents  the 
usual  position,  which  is  wrong,  giving  rise  to  vomiting,  because  it  forms  a  pouch  into 
which  the  contents  of  the  jejunum  may  empty. 

Taken  from  Dr.   \V.  J.   Mayo's  original  drawing. 


PLATE  LXXXVI. 

G  ASTRO-  EXTEROSTO  MY. 

Represent  anterior  gastro-enterostomy   \vith   the  omentum   folded  over  the  point 
of  union  between  the  stomach  and  the  jejunum  to  increase  the  safety  of  the  operation. 
Taken  from  Dr.   \V.   J.   Mayo's  original   drawing. 


PLATE  LXXXVII. 

G  ASTRO-  EXTEROSTOMY. 

Anterior   gastro-enterostomy.      The   jejunum   being   united   to   the   stomach   at   its 
lowest  point,  which  will  prevent  the  regurgitation  of  bile,  "vicious  circle." 
Taken  from  Dr.  W.  J.  Mayo's  original  drawing. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  577 

of  the  stomach,  but  here  we  find  the  large  artery,  the  gastro-epiploic,  Plate 
LXXXV  b,  with  its  large  branches  extending  at  right  angles  with  the  greater 
curvature  of  the  stomach.  We  will  select  a  point  half  way  between  two  of 
these  branches  and  make  our  incision  through  the  peritoneal  and  muscular 
coats  down  to  the  mucous  coat.  The  muscular  coat  will  retract  somewhat, 
and  here  again  we  exercise  the  same  care  in  inserting  the  purse-string 
suture  near  the  edge  of  the  wound,  in  order  not  to  draw  too  much  tissue 
between  the  rims  of  the  button.  The  smaller  segment  of  the  button  is 
now  inserted  and  the  purse-string  suture  tied.  It  has  been  so  applied  as  to 
avoid  having  the  knots  in  the  two  sutures  meet  when  the  button  has  been 
closed.  After  withdrawing  the  pledget  of  cotton  from  the  opening,  the 
two  segments  of  the  button  are  adjusted  to  each  other  and  pressed  together 
with  a  moderate  amount  of  force,  care  being  taken  to  push  in  any  small 
portion  of  serous  surface  which  might  not  have  adjusted  itself  spontaneously. 

In  doing  the  anterior  gastro-enterostomy  it  is  wise  to  add  Hartmann's 
suggestion  of  stitching  the  intestine  to  the  stomach  wall  an  inch  above  the 
proximal  side  with  a  mattress  suture.  A  second  suture  is  placed  in  same 
manner  about  one  inch  on  the  distal  side  of  the  anastomosis.  This  prevents 
the  jejunum  from  kinking  on  the  gastro-jejunal  opening. 

It  is  again  important  to  select  the  lowest  point  in  the  stomach,  in  order 
to  secure  perfect  drainage  of  this  organ,  and  especially  for  the  purpose  of 
preventing  the  flow  of  bile  from  the  duodenum  into  the  stomach.  It  is  also 
important  to  remain  as  great  a  distance  from  the  diseased  portion  of  the 
organ  as  is  compatible  with  securing  the  most  dependent  portion ;  fortunate- 
ly, the  latter  usually  lies  very  well  to  the  left. 

In  patients  who  are  greatly  reduced  in  strength  it  is  well  to  reinforce 
the  Murphy  button  to  a  certain  extent  by  the  use  of  a  cuff  formed  out  of  the 
omentum,  as  shown  in  Plate  LXXXVI. 

It  has  occasionally  happened  after  a  gastro-enterostomy  in  greatly  re- 
duced patients,  that  a  sudden  motion,  such  as  would  be  experienced  during  a 
severe  paroxysm  of  coughing,  sneezing-  or  vomiting,  would  be  followed  by  a 
loosening  of  the  anterior  portion  of  the  union  between  the  stomach  and  the 
intestine.  In  these  cases  it  is  wise  to  enforce  this  union  by  employing  the 
omentum,  which  is  always  well  nourished  and  abundantly  supplied  with 
blood  vessels,  and  will  consequently  make  up  for  the  deficiencies  in  the  nu- 
trition of  the  stomach  wall. 

Non-operative  Cases. 

In  case  an  operation  is  refused  by  a  patient  in  this  condition,  we  try  to 
secure  a  degree  of  comfort  by  the  use  of  opium.  We  also  teach  him  to  per- 
form gastric  lavage  whenever  he  is  nauseated.  In  many  of  these  patients 
one  can  secure  a  great  degree  of  comfort  by  pursuing  the  following  plan : 
Gastric  lavage  is  performed  in  the  morning  directly  before  taking  breakfast, 
which  should  consist  as  much  as  possible  of  food  that  can  be  absorbed  from 
the  stomach,  therefore  liquid,  in  order  not  to  clog  whatever  slight  opening 
may  still  exist  in  the  pylorus.  Two  hours  later  the  remnants  of  this  food 
are  again  removed  by  gastric  lavage.  The  same  plan  is  followed  at  noon 
and  at  night.  In  this  manner  the  food  is  not  mixed  with  decomposing  mucus 
and  remains  from  a  previous  meal,  which  are  partly  decomposed  and  partly 
digested. 

After  a  short  period  of  practice  these  patients  frequently  enjoy  this 
plan,  and  many  of  them  improve  greatly  in  appearance,  because  they  no 
longer  have  to  absorb  these  products  of  decomposition.  It  is  not  infrequent 


5/8  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

for  patients  to  gain  in  weight  under  this  form  of  treatment,  and  there  is 
usually  a  great  reduction  in  pain  in  cases  in  which  this  symptom  is  marked. 
A  fear  of  producing  hemorrhage  by  the  use  of  gastric  lavage  has  been 
expressed,  but  we  believe  that  this  danger  is  greatly  over-estimated.  Be- 
fore we  became  familiar  with  the  use  of  the  Murphy  button,  we  had  oc- 
casion to  treat  many  cases  in  the  manner  just  described,  and  never  found 
any  difficulty  from  hemorrhage. 

RESECTION   OF  THE  PYLORUS. 

Had  we  encountered  a  removable  tumor  of  the  pylorus  in  the  case 
above  outlined,  our  treatment  would  not  have  varied  as  regards  the  com- 
munication between  the  stomach  and  the  intestine,  but  this  would  have  been 
preceded  by  the  excision  of  the  pylorus  by  a  method  which  will  be  described 
presently. 

There  are  several  valid  reasons  for  preferring  a  gastro-enterostomy, 
such  as  has  been  described,  to  a  direct  end-to-end  union  between  the  stom- 
ach and  the  duodenum  after  the  excision  of  the  pylorus :  I.  It  is  much  more 
easily  accomplished ;  2.  The  operation  requires  much  less  time,  which  is  an 
important  feature  in  many  of  these  cases  ;  3.  Surfaces  completely  covered 
with  peritoneum  can  be  united;  4.  There  is  no  tension;  5.  The  adjustment 
can  be  made  more  accurately,  because  in  the  end-to-end  approximation  of 
the  duodenum  to  the  stomach  there  is  a  great  difference  in  the  lumen  which 
varies  with  the  amount  of  tissue  that  has  to  be  removed  from  the  stomach; 
6.  The  attachment  being  at  the  most  dependent  portion  of  the  stomach,  the 
drainage  is  more  likely  to  be  satisfactory. 

With  the  hearty  consent  of  Dr.  W.  J.  Mayo  the  following  extract  is 
used.  His  work  in  this  field  is  classical  and  authoritative.  The  accom- 
panying illustrations  are  also  taken  from  his  original  drawings. 

Radical  Operations  for  the  Cure  of  Cancer  of  the  Pyloric  End  of  the  Stomach. 

[Seventy  per  cent,  of  all  gastric  carcinomata  involve  the  pyloric  por- 
tion, and  sixty  per  cent,  have  their  origin  at  the  pylorus  or  within  three 
inches  of  it.  Considering  the  fact  that  radical  operation  was  successfully 
performed  in  the  time  of  Billroth  (1881),  before  the  inception  of  modern 
abdominal  surgery,  and  that  during  the  succeeding  years  more  or  less  work 
has  been  done  in  this  field,  it  is  curious  that  pylorectomy  and  partial 
gastrectomy  have  not  as  yet  achieved  an  accepted  surgical  position.  There 
have  been  a  number  of  reasons  for  this  anomaly ;  first,  a  belief  that  the 
diagnosis  could  not  be  made  before  the  case  had  advanced  beyond  the  pos- 
sibility of  cure,  and,  second,  that  the  operation  was  difficult,  prolonged  and 
bloody,  with  an  almost  prohibitive  mortality.  The  first  proposition  is  to 
a  considerable  extent  true  ;  but  not  entirely  so,  as  we  have  in  exploratory 
incision  the  one  diagnostic  resource  which  is  reliable  and  which  must  be 
resorted  to  in  the  large  majority  of  cases  before  a  surgical  diagnosis  can 
be  made.  Without  it  the  truth  is  but  slowly  established  together  with  prog- 
ressive hopeless  involvement.  Exploration  can  be  safely  accomplished 
through  a  small  incision  and  with  a  short  time  of  disability.  Tt  is  said  that 
the  patient  will  not  submit  to  an  abdominal  incision  upon  suspicion.  Herein 
we  do  the  intelligence  of  the  public  an  injustice;  we  have  seldom  been 
refused  the  opportunity,  when  the  matter  has  been  fairly  and  candidly  laid 
before  the  patient  and  his  friends.  The  plea  for  delay  has  more  often  come 
from  the  attending  physician. 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  579 

Without  going  into  the  question  as  to  the  symptoms  which  would  con- 
stitute a  basis  for  exploration,  the  writer  would  express  the  opinion  that 
the  early  diagnosis  must  be  based  upon  clinical  phenomena,  the  result  of 
observation  and  experience. 

Some  Misleading  Statements. 

In  attempting  to  solve  some  of  these  problems  we  have  encountered 
a  number  of  misleading  statements,  which  seem  to  have  been  generally 
accepted.  Of  these,  three  are  of  sufficient  importance  to  deserve  brief  dis- 
cussion :  (a)  The  value  of  laboratory  methods  of  diagnosis;  (b)  the  signifi- 
cance of  a  palpable  tumor;  (c)  the  history  of  previous  ulcer. 

(a)  Laboratory  methods  of  diagnosis  are  chiefly  based  upon  the  chem- 
istry of  the  gastric  secretions  (test  meals  and  so  forth)  and  the  microscopical 
examination  and  chemical   reactions  of  gastric  "findings,"  as  well  as  the 
urine,  feces  and  blood.     In  the  surgical  stage  these  examinations  have  little 
value,  but  gain  in  diagnostic  importance  with  the  progress  of  the  disease, 
to  become  of  the  greatest  value  only  when  the  patient  is  in  a  hopeless  con- 
dition.   My  colleagues,  Drs.  Graham  and  Millet,  in  the  examination  of  some- 
what over  1.500  stomach  and  duodenal  cases,  of  which  430  came  to  opera- 
tive demonstration,  showed  this  beyond  question.    These  examinations  should 
be  made,  but  exploration  should  not  be  delayed  by  reason  of  the  inconclusive 
nature  of  the  results. 

(b)  Tumor. — The  dictum  was  advanced  many  years  ago  that  the  pres- 
ence of  a  tumor  of  itself  demonstrated  inoperability.     This  is  by  no  means 
true ;  a  small  movable  tumor  in  the  pyloric  region  may  be  a  favorable  indica- 
tion.    The  early  diagnosis  of  cancer  depends  in  a  great  measure  upon  the 
introduction  of  mechanical  phenomena  from  obstruction  at  the  pylorus,  late 
vomiting,  dilatation,  pain,  gas,  etc.,  with   or  without  palpable  tumor,  and 
it  is  the  interference  with  gastric  motility — the  progress  of  food  from  the 
stomach — which  early  calls  the  attention  of  the  patient  to  his  trouble,  and 
not  the  presence  of  the  cancer  itself.     Without  these  symptoms  a  surgical 
diagnosis  would  seldom  be  made.    In  our  experience  the  patient  with  marked 
symptoms  of  cancer  of  the  stomach,  but  without  any  evidence  of  pyloric 
obstruction,  proves  on  exploration  to  be  the  victim  of  advanced  and  hopeless 
disease  of  the  body,  in  which  there  were  no  symptoms  during  the  operable 
period. 

fc)  A  history  of  previous  ulcer  with  complete  recovery  during  a  pro- 
longed period  of  time  is  apt  to  be  taken  as  an  indication  that  a  present  gastric 
trouble  is  due  to  a  recurrence  of  the  ulcer  and  lead  the  patient  and  attendant 
physician  to  postpone  interference.  Usually  this  is  true,  but  too  often  the 
renewal  of  symptoms  is  due  to  cancer  development  upon  an  ulcer  base.  We 
have  had  this  occur  a  number  of  times.  The  author  has  become  a  convert 
to  the  belief  that  cancer  frequently  developes  upon  an  old  ulcer  scar.  Graham, 
in  145  cases  of  cancer  of  the  stomach  which  came  to  operation  at  our  hands, 
found  a  previous  history  of  ulcer  in  sixty  per  cent  of  the  cases,  although 
years  may  have  elapsed  after  healing  of  the  ulcer  before  the  cancer  began. 
Lehert  says  that  nine  per  cent  of  ulcers  develop  cancer — that  is,  pass  directly 
from  the  one  condition  to  the  other.  Ochsner,  Fiitterer,  Dunn  and  others 
believe  that  the  irritation  of  healed  ulcer  defects  in  the  mucosa  furnish  the 
starting  point  for  the  majority  of  cancers.  Murphy  rightly  says  that  pre- 
cancerous  lesions  can  usually  be  demonstrated  in  the  history  of  the  case. 
It  is  to  be  noted  that  the  topography  of  cancer  and  ulcer  is  nearly  identical. 


580  SURGERY    OF    THE    ESOPHAGUS    AND    STO'MACH 

The  Determination  of  Operative  Intervention. 

The  second  proposition  concerns  the  operation  itself.  There  are  two 
local  manifestations  of  the  malignant  process  upon  which  the  advisability 
of  operation  depends:  (a)  Local  extent  of  disease;  (b)  lymphatic  involve- 
ment. 

(a)  Movability  of  the  growth  is  a  very  important  factor  in  judging 
of  the  extent  of  disease.     Limitation  to  the  pyloric  end  of  the  stomach  is 
also  of  prime  importance.    Extension  to  neighboring  organs  usually  contra- 
indicates  operation,  with  the  occasional  exception  of  the  transverse  meso- 
colon.     The  duodenum  is  rarely  involved  to  any  considerable  extent.     Ad- 
resions  are  a  serious  complication,  not  only  because  they  are  the  advance 
guard  of  the  cancerous  process,  but  in  that  they  add  to  the  difficulties  and 
dangers  of  the  operation.     Haberkant  found  a  death  rate  of  seventy-three 
per  cent  operated  upon  in  the  face  of  extensive  adhesions,  and  twenty-seven 
per  cent  without  such  complication.     Mikulicz  had  a  mortality  of  seventy 
per  cent  when  there  was  close  adhesion  to  the  pancreas.    A  moderate  amount 
of  adhesions  which  permit  of  free  motility  of  the  growth  have  not  materially 
influenced  the  prognosis  in  our  experience. 

(b)  Lymphatic  infection.     This  is  the  most  important  element  in  the 
attempt  at  cure  of  cancer  of  the  stomach,  because  the  most  difficult  to  esti- 
mate in  its  extent.     The  mere  presence  of  enlarged  lymph  nodes  does  not 
necessarily  imply  cancer.    Glandular  hyperplasia  occurs  with  great  frequency 
in  ulcer  as  the  result  of  infection,  and  the  location  of  such  lymph  nodes 
may  lead  to  the  site  of  ulceration,  as  pointed  out  by  Lund.     Ulcerating  gas- 
tric carcinomata  may  give  rise  to  infected  glands  without  epithelial  invasion, 
but  in  practically  all  cases  of  gastric  cancer  the  lymphatic  structures  are 
involved.      In  the   Breslau   clinic  twenty   cases  out   of  twenty-one   showed 
glandular  involvement.     In  a  general  way  the  lymph  channels  follow  the 
blood  vessels.     On  the  lesser  curvature  the  blood  and  lymph  vessels  lie  in 
the  wall  of  the  stomach  itself,  and,  as  pointed  out  by  Mikulicz,  it  is  necessary 
in  every  case  of  pyloric  cancer  to  remove  all  of  the  lesser  curvature  to  the 
gastric  artery.     For  convenience  this  situation  on  the  lesser  curvature  for 
beginning  of  the  line  of  excision  may  be  called  the  Mikulicz  point  of  election. 

To  Cuneo  we  owe  a  debt  of  gratitude  for  his  masterly  exposition  of  the 
lymph  drainage  of  the  stomach.  He  showed  that  there  are  but  few  lymph 
glands  along  the  greater  curvature,  and  these  are  confined  to  the  pyloric 
region.  (See  Plate  LXXXVIIT.)  These  glands,  with  the  blood  vessels,  lie  at 
some  distance  from  the  greater  curvature,  thus  enabling  rapid  expansion  and 
contraction  of  the  stomach  without  interference  with  the  circulation.  The 
lymph  stream  in  this  situation  flows  from  left  to  right  and  does  not  drain 
more  than  one-third  of  the  adjacent  stomach,  two-thirds  going  into  the  lymph 
channels  of  the  lesser  curvature.  Tn  the  immediate  vicinity  of  the  pylorus, 
however,  it  drains  its  fair  share. 

The  lymphatics  of  the  greater  and  lesser  curvatures  enter  the  deep 
receiving  glands  about  the  cceliac  axis  on  the  anterior  surface  of  the  aorta. 
Cuneo  practically  demonstrated  that  the  fundus  and  two-thirds  of  the 
greater  curvature  are  free  from  lymphatic  involvement  in  cancer  of  the 
pylorus.  Hartmann  at  once  seized  upon  this  basic  principle  and  fixed  the 
point  of  election  for  the  line  of  section  upon  the  greater  curvature  at  a 
healthy  place  on  the  gastric  wall,  to  the  left  of  these  glands.  The  distance 
to  the  left  is  regulated  by  the  extent  of  the  disease. 

In  a  previous  communication  the  author  called  attention  to  the  lymphatic 


fated 


PLATE  LXXXVIII. 
STOMACH  SHOWING  DISTRIBUTION  OF  LYMPH  NODES. 

As   demonstrated  by    Ilartmann  and   Cuneo. 
(From  Dr.  W.  J    May's  original  drawings.) 


SURGERY    OF    THE     ESOPHAGUS    AND    STOMACH  583 

isolation  of  the  dome  of  the  stomach.  This  has  also  been  noted  by  Robson 
and  Moynihan.  It  is  evident  that  the  extent  of  this  free  zone  along  the 
greater  curvature  is  much  wider  in  pyloric  cancer  than  was  at  that  time 
considered  possible.  The  retention  of  this  portion  of  the  stomach  relieves 
the  operation  of  many  serious  difficulties  without  loss  of  completeness. 

Operative  Detail. 

The  operation  itself  can  be  divided  into  (a)  incision  and  exposure; 
(b)  control  of  hemorrhage;  (c)  closure  of  the  stomach  and  duodenal  stum-ps; 
(d)  re-establishment  of  the  gastro-intestinal  canal;  (e)  avoidance  of  in- 
fection; (f)  measures  for  preventing  shock. 

The  patient's  stomach  should  be  cleansed  the  day  before,  rather  than 
immediately  previous  to  operation,  as  it  may  prove  to  be  somewhat  trying 
to  one  unaccustomed  to  the  process.  A  small  amount  of  liquid  nourishment 
may  be  given  after  the  lavage,  but  nothing  on  the  morning  of  the  operation. 
The  teeth  and  mouth  should  have  been  previously  cleansed  as  well  as 
possible.  A  preliminary  hypodermatic  injection  of  morphine,  to  enable  the 
anesthetic  to  be  reduced  to  a  minimum,  may  be  of  value. 

(A)  A  small  incision  is  made  in  the  median  line,  half  way  between  the 
ensiform  cartilage  and  the  umbilicus ;  through  this  two  fingers  are  intro- 
duced for  exploration.     If  the  condition  is  inoperable,  the  incision  is  closed 
and  a  sufficient  number  of  buried,  non-absorbable  mattress  sutures  of  silk, 
linen  or  wire  introduced  into  the  aponeurotic   structure  of  the  linea  alba 
to  enable  the  patient  to  get  about  at  once  and  to  return  to  his  home  and 
friends  within  a  few  days.     If  sutured  in  the  usual  manner  and  the  patient 
placed  in  bed  for  two  or  three  weeks,  many  of  them  will  develop  hypostatic 
pulmonary  lesions,  loss  of  appetite,  swelling  of  the  feet  and  so  forth,  and 
may  be  unable  to  spend  their  few  remaining  days  at  home.     When  an  ad- 
vanced cancer  case  goes  to  bed  for  a  week  or  two  the  chances  of  his  getting 
about  again  are  small. 

Xon-absorbable  sutures,  buried  in  fixed  structures  such  as  fascia  and 
bone,  seldom  give  trouble  and  furnish  immediate  strength.  In  muscle  and 
movable  tissues  atrophy  necrosis  may  occur.  "We  limit  their  use,  however, 
to  the  hopeless  cases  of  exploration  for  malignant  disease.  If  operation 
is  decided  upon,  the  small  exploring  incision  is  rapidly  enlarged  to  four 
or  five  inches  and  a  sufficiency  of  the  gastro-hepatic  omentum  is  tied  off  at 
once  close  to  the  liver.  This  opens  the  lesser  cavity  of  the  peritoneum 
and  mobilizes  the  pyloric  end  of  the  stomach  with  tumor.  The  entire  area 
is  now  packed  off  with  gauze  pads. 

(B)  Control  of  hemorrhage.     The  pyloric  end  of  the  stomach  is  sup- 
plied by  four  blood  vessels,  the  gastric  and  superior  pyloric  above,  and  the 
right  and  left  gastro-epiploics  below.     By  ligating  these  four  vessels,  early 
the  operation  is  rendered  practically  bloodless.     The  gastric  is  doubly  tied 
about  one  inch  below  the  cardiac  orifice  at  a  point  where  it  joins  the  lesser 
curvature  and  divided  between  the  ligatures.    The  superior  pyloric  is  doubly 
tied  and  divided.     The  fingers  are  passed  beneath  the  pylorus,  raising  the 
gastro-colic  omentum  from  the  transverse  meso-colon,  and  in  this  way  safe 
ligation  behind  the  pylorus  of  the  right  gastro-epiploic  artery,  or  in  most 
cases  its  parent  vessel,  the  gastro-duodenal,  is  secured.    (Plate  LXXXIX.) 
The  left  gastro-epiploic  is  now  tied  at  an  appropriate  point  and  the  necessary 
amount  of  gastro-colic  omentum  doubly  tied  and  cut.     Sometimes  the  right 
margin  of  the  omentum  becomes  very  much  congested  from  the  venous 
obstruction  produced  in  this  way.     In  a  few  cases  it  has  seemed  wise  to 


584  SURGERY    OF    THE    ESOPHAGUS    AND    STOJMACH 

excise  the  devitalized  omentum,  especially  if  drainage  is  to  be  used,  with 
its  attendant  possibilities  of  secondary  infection.  In  one  such  case  a  con- 
siderable amount  of  omentum  tissue  sloughed,  although  fortunately  the 
patient  recovered.  If  drainage  is  not  used  it  will  act  as  an  omental  graft 
and  give  no  trouble.  It  is  important  that  in  ligating  the  gastro-duodenal 
vessel  and  the  gastro-colic  omentum  the  fingers  should  raise  the  structures 
away  from  the  middle  colic  artery  which  runs  immediately  beneath  in  the 
transverse  meso-colon.  (Plate  XC. ) 

The  lesser  cavity  of  the  peritoneum  is  a  potential  rather  than  an  actual 
space,  as  the  two  layers  of  peritoneum  are  in  contact,  and  the  middle  colic 
has  been  accidentally  caught  in  tying  the  vessels  from  without  inward.  As 
this  vessel  usually  is  the  entire  supply  of  the  transverse  colon  ligation  may 
result  in  gangrene  of  the  transverse  colon,  as  pointed  out  by  Kronlein.  This 
has  happened  a  number  of  times. 

The  control  of  hemorrhage  is  very  similar  to  the  ligation  of  the  four 
vessels  concerned  in  abdominal  hysterectomy  and  fully  as  easy. 

(C)  The  duodenum  is  doubly  clamped  and  divided  between  with  the 
actual  cautery  to  prevent  inoculation  of  the  cut  surfaces  with  cancer.  (Plate 
XC.)  The  stump  should  be  left  one-fourth  inch  long,  and  before  removing 
the  clamp  a  running  suture  of  catgut  is  introduced  through  the  seared  stump 
and  tied  as  the  clamp  is  removed.  A  pursestring  suture  of  silk  or  linen, 
three-quarters  of  an  inch  below  the  stump,  enables  inversion  in  a  similar 
manner  to  the  stump  of  the  appendix.  (Plates  XCI  and  XCII.)  A  long 
Kocher  clamp  is  now  placed  from  the  tied  gastric  artery  at  Mikulicz's  point 
of  election,  in  an  oblique  direction,  so  as  to  save  as  much  as  possible  of  the 
greater  curvature  to  Hartmann's  point  of  election  on  the  greater  curvature. 
(Plate  XCI.)  The  blades  of  this  clamp  should  be  covered  with  rubber  tub- 
ing and  the  compression  should  be  just  sufficient  to  retain  the  tissues  in  its 
grasp.  A  second  clamp  is  applied  on  the  tumor  side  to  prevent  leakage.  The 
tissues  between  are  severed  with  the  Pacquelin  cautery,  one-quarter  of  an  inch 
from  the  holding  clamp,  and  as  the  tissues  are  divided  several  catch  forceps 
are  applied  to  the  projecting  stump  to  prevent  retraction  of  some  part  of 
the  gastric  wall  from  the  grasp  of  the  Kocher  clamp.  The  pyloric  end  of 
the  stomach,  with  the  tumor  guarded  against  leakage  by  the  clamp  at  each 
end,  is  removed.  The  cauterized  stump  projecting  beyond  the  Kocher  clamp 
is  rapidly  sutured  with  a  catgut  button-hole  suture,  from  the  greater  to 
the  lesser  curvature,  through  all  the  coats  of  the  stomach,  and  in  the  same 
manner  directly  back,  and  tied  at  the  starting  point ;  this  prevents  hemorrhage 
as  well  as  leakage.  The  doubling  of  this  form  of  suture  holds  the  approxi- 
mated edges  evenly  in  line.  The  Kocher  clamp  is  now  removed  and  any 
bleeding  point  caught  and  tied. 

The  final  suture,  of  silk  or  linen,  is  now  introduced  and  made  after 
the  right-angled  plan  of  Gushing.  It  is  taken  sufficiently  far  from  the  cat- 
gut suture  line  to  enable  easy  approximation  of  the  sero-muscular  layers 
without  tension.  (Plate  XCII.) 

Steps  (d)  and  (c)  can  be  varied  sometimes  to  advantage.  We  have 
frequently  tied  off  the  gastro-hepatic  ligament  and  the  superior  vessels  and 
at  once  double  clamped  and  divided  the  duodenum.  By  pulling  upward  on 
the  stomach  side  the  gastro-duodenal  artery  is  easily  caught,  tied  and  divided, 
and  the  operation  proceeded  with  as  before.  In  a  few  cases  we  have  begun 
on  the  stomach  side,  ligating  and  dividing  the  gastric  and  left  gastro- 
epiploic  vessels  first,  then  clamping,  dividing  and  suturing  the  stomach  as 


PLATE  LXXXIX. 
STOMACH  WITH   CARCINOMA  OF  PYLORUS. 

Showing  lines  chosen  in  making  pylorectomy  or  partial  gastrectomy  by  vari- 
ous   surgeons. 

(From  original  drawings  of  Dr.  W.  J.  Mayo.) 


PLATE  XC. 

STOMACH  WITH  CARCINOMA  OF  PYLORUS. 

Showing  manner  of  applying  forceps  to  duodenum  and  also  ligation  of  lesser 
omentum.     Also  showing  lymph  nodes  usually  involved  and  line  of  excision  in 


early  cases. 


[From  original  drawing  of  Dr.  \Y.  J.   Mayo.) 


PLATE  XC1. 
PYLORECTOMY   WITH   PARTIAL  GASTRECTOMY. 

Showing  iigation  of  lesser  and  greater  omentum.  also  application  of  clamps 


to  duodenum 
place. 


and  to   stomach.     Also  circular  and  end-sutures   of  duodenum   m 
(From  original  drawings  by  Dr.  \V.  J.  Mayo.) 


J.  MAYO. 


PLATE  XCII. 
PYLORECTOMY  WITH  PARTIAL  GASTRECTOMY  FOR  CARCINOMA  OF  PYLORUS. 

Showing  manner  of  closing  end  of  pylorus  and  stomach,  also  ligation  of  all 
vessels. 

(From   Dr.  \V.  J.   Mayo's  original  drawing.) 


William  J.MAYO. 


PLATE  XCIII. 
PYLORECTOMY    WITH    PARTIAL    GASTRECTOMY    WITH    GASTRO-JEJUNOSTOMY    OPERATION 

COMPLETED. 
(From  Dr.  W.  J.  Mayo's  original  drawing.) 


SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  595 

before,  completing  the  duodenal  end  with  its  vessels  last.  This  is  favored 
by  Hartmann.  If  there  are  adhesions,  however,  the  first  plan  mobilizes  the 
stomach  much  better  and  enables  more  accurate  work  and  greater  exposure 
of  that  part  of  the  stomach,  which,  at  the  line  of  section,  lies  naturally  deep 
under  the  costal  arch. 

(D)  Restoration  of  the  gastro-intestinal  canal  was  first  accomplished 
by  Billroth,  by  joining  directly  the  cut  surface  of  the  duodenum  to  the 
shortened  stomach,  the  opening  of  the  latter  viscus  being  partly  sutured 
to  reduce  it  to  the  size  of  the  duodenal  end.     The  angle  where  the  three 
suture  lines  come  together  leaked  so  often,  especially  if  there  was  the  least 
tension,  that  it  was  called  the  "fatal  suture  angle."    Kocher  saw  the  defect 
in  this  method  and  began  implanting  the  cut  end  of  the  duodenum  to  the 
posterior  gastric  wall  at  a  sound  point,  and  completely  closed  the  stomach. 
This  method  gives  excellent  results,  if  there  be  no  tension  in  bringing  the 
parts  into  easy  apposition.     Unfortunately  this  often  happens. 

Billroth's  second  operation  is  the  operation  of  choice: — Complete  clos- 
ure of  the  duodenal  and  stomach  ends  with  an  independent  gastro-jejunos- 
tomy  of  the  usual  type.  It  has  the  two  chief  requisites  of  gastro-intestinal 
anastomosis ;  there  is  no  tension  and  the  parts  to  be  united  have  not  been 
injured.  Either  the  anterior  or  posterior  method  can  be  used  and  the  Mur- 
phy button  or  suture  operation  be  performed.  If  the  patient  is  in  good  con- 
dition and  the  operation  has  been  completed  promptly,  we  prefer  the 
posterior  suture  method  ;  if  the  patient's  condition  is  poor,  the  anterior  button 
operation  is  chosen.  (Plate  XCIII.) 

(E)  Infections.     The  question  of  cancer  infection  grafted  upon  a  raw 
surface  is  an  important  one.     We  have  seen  carcinomatous  nodes  develop 
in  the  abdominal  incision,  and  in  the  abdominal  needle  punctures  made  in 
suturing  the  abdominal  wall  after  partial  gastrectomy.     Dissemination  of 
carcinoma  by  rough  handling  or  allowing  infected  cells  to  escape  into  the 
wound  is  not  uncommon.     It  is  for  this  reason  that  all  sections  of  the  dis- 
eased part  are  made  with  the  actual  cautery,  which  prevents  inoculation  of 
raw   surfaces,   checks   capillary   hemorrhage   and   leaves  the   approximated 
ends  in  an  aseptic  condition  until  they  are  digested  back  to  the  outer  suture 
line.     Pyogenic  infection  is  prevented  by  the  clamps  placed  upon  each  side 
of  the  excised  stomach,  sealing  against  escape  of  contents,  while  the  exposed 
edges  beyond  the  clamp  are  sterilized  by  the  use  of  the  cautery  in  making 
the  section.     In  addition  to  this  the  gauze  pads  are  arranged  in  two  rows, 
an  outer,  deep  layer  which  is  not  changed  until  final  removal,  and  an  inner, 
superficial  layer,  which  is  being  constantly  renewed.     Upon  removal  of  the 
final  gauze  pack  the  entire  field  is  carefully  gone  over  and  any  little  bleeding 
point  checked  by  ligature.     After  sponging  the  surfaces  with  a  moist  saline 
gauze  pad,  the  abdominal  incision  is  closed. 

In  some  cases  drainage  seems  wise  on  account  of  accidental  soiling. 
This  is  seldom  necessary  but  if  in  doubt,  drain,  and  best  with  a  cigarette 
drain  placed  at  the  lower  angle  of  the  external  wound,  entirely  away  from 
the  visceral  suture  lines.  The  internal  end  of  the  drain  should  reach  to  a 
situation  just  above  the  transverse  colon,  which  acts  as  a  dam  when  the 
patient  is  placed  in  the  proper  position  in  bed — head  and  shoulders  elevated. 
In  this  half-sitting  posture  the  little  pouch  formed  by  the  transverse  colon 
is  not  unlike  an  artificial  pelvis  into  which  any  fluids  gravitate.  If  there  be 
but  a  limited  area  to  be  quarantined,  as  from  slow  perforation,  the  drain 
should  be  brought  out  in  the  most  direct  manner  possible. 


596  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

(F)  Shock.  If  the  patient  is  in  good  condition  there  is  practically  no 
shock  because  there  is  no  blood  loss  and  little  exposure  of  abdominal  contents. 
The  operation  proceeds  systematically  and  can  be  done  in  a  suitable  case  by 
the  average  operator,  from  the  beginning  of  the  abdominal  incision  until  it  is 
closed,  in  from  fifty  minutes  to  one  hour  and  fifteen  minutes.  If  the  patient's 
condition  is  very  poor,  owing  to  early  obstruction,  the  chief  danger  comes 
from  the  lack  of  fluids  in  the  body.  As  suggested  to  us  by  Dudley  Allen, 
this  should  be  made  up  by  subcutaneous  infusions  of  saline  solution,  forty 
to  sixty  ounces  a  day,  usually  twenty  to  thirty  ounces  every  twelve  hours, 
for  two  days  previous  to  the  operation.  This  is  continued  for  several  days 
following  operation  if  necessary.  In  these  dehydrated  patients  it  is  almost 
impossible  to  get  sufficient  fluids  into  them  in  any  other  manner.  For  sub- 
cutaneous infusions  we  prefer  the  ordinary  Davidson  syringe,  to  which  I 
attach  an  aspirating  needle.  The  hand  bulb  enables  nice  regulation  of  the 
inflow.  The  whole  can  be  boiled  and  the  infusion  given  by  a  nurse  as  easily 
as  an  enema.  In  debilitated  patients  very  little  anesthetic  is  used,  just 
enough  to  enable  the  surgeon  to  open  and  close  the  abdomen.  All  of  the 
visceral  work  can  be  done  without  pain.  The  previous  exhibition  of  morphia 
keeps  the  patient  from  becoming  nervous. 

An  enema  of  six  ounces  of  coffee  is  given  as  soon  as  the  patient  is 
put  to  bed.  If  necessary  morphia,  strychnine  and  so  forth  are  exhibited. 

The  after-treatment  is  simple,  the  head  and  shoulders  of  the  patient 
are  raised  by  four  or  five  pillows,  rectal  alimentation  is  instituted,  hot  water 
by  mouth  after  twelve  hours  in  tablespoonful  doses,  increased  to  an  ounce 
every  hour.  After  thirty-six  hours  the  usual  experimentation  with  liquid 
foods  is  begun. 

To  recapitulate,  there  are  six  important  stages  to  the  operation  as 
outlined : 

Step  i. — Open  the  abdomen. 

Step  2. — Double  ligate  and  divide  the  gastric  artery,  ligate  and  divide 
the  necessary  amount  of  gastro-hepatic  omentum  close  to  the  liver,  leaving 
most  of  its  structure  attached  to  the  stomach.  Double  ligate  and  divide 
the  superior  pyloric  artery  and  free  the  upper  inch  or  more  of  the  duodenum. 
(Plate  XC.) 

Step  J. — With  the  fingers  as  a  guide  underneath  the  pylorus,  in  the 
lesser  cavity  of  the  peritoneum,  ligate  the  right  gastro-epiploic  or  gastro- 
duodenal  artery  and  progressively  tie  and  cut  away  the  gastro-colic  omentum 
distal  to  the  glands  and  vessels  up  to  the  appropriate  point  on  the  greater 
curvature,  and  here  ligate  the  left  gastro-epiploic  vessels.  (Plate  XCI.) 

Step  4. — Double  clamp  the  duodenum,  divide  between  with  the  cautery, 
leaving  one-fourth  inch  projection.  With  a  running  suture  of  catgut  through 
the  seared  stump  the  end  of  the  duodenum  is  closed  as  the  clamp  is  re- 
moved. A  purse-string  suture  about  the  duodenum  enables  the  stump  to 
be  inverted.  (Plate  XCII.)  The  proximal  end  of  the  stomach  is  double- 
clamped  along  the  Mikulicz-Hartmann  line  and  divided  with  the  cautery, 
leaving  one-fourth  inch  projection.  Suture  through  the  seared  stump  with 
a  catgut  button-hole  suture.  This  is  again  turned  in  after  removal  of  the 
clamp  by  a  continuous  silk  or  Gushing  suture.  (Plates  XCII  and  XCIII.) 

Step  5. — Independent  gastro-jejunostomy.     (Plate  XCIII.) 

Step  6. — Closure  of  the  wound. 

[The  operation  herein  described,  with  a  mortality  of  one  in  fifteen 
should  be  the  operation  of  choice  for  the  average  case  of  fairly  early  disease 
of  the  pyloric  region. — W.  J.  MAYO,  A.  M.,  M.  D.] 


PLATE  XCVI. 

Showing  application  of  stitches  in  the  gastro-hepatic  omentum  in  Beyer's  opera- 
tion for  gastroptosis. 


\ 
SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH  599 

GASTROPTOSIS. 

The  condition  of  gastroptosis  is  rarely  found  except  in  a  complicated 
form.  It  is  usually  associated  with  a  condition  of  general  enteroptosis  in 
which  all  of  the  intra-abdominal  organs  are  more  or  less  prolapsed.  Thus, 
for  example,  when  the  patient  is  in  the  erect  position  the  liver  is  below  the 
normal  line ;  the  kidneys,  especially  the  right  one,  are  lower  than  normal ; 
the  transverse  colon,  cecum  and  small  intestines  are  low  down  in  the  abdo- 
men. Several  years  ago  many  of  these  patients  were  subjected  to  a  gastro- 
enterostomy,  in  the  hopes  that  gastric  drainage  might  relieve  their  gastric 
disturbances,  but  the  results  were  most  unsatisfactory. 

Patients  suffering  from  gastroptosis  are  usually  thin  and  are  often  tall 
and  nearly  always  of  a  nervous  temperament.  They  complain  of  chronic 
stomach  trouble  characterized  by  discomfort  after  eating,  bloating  and 
eructation  of  gas.  Nausea  and  vomiting  are  not  uncommon,  and  usually 
a  stomach  splash  can  be  found  in  the  lower  portion  of  abdomen  several  hours 
after  eating.  Constipation  is  usually  present. 

The  physical  sign  of  gastroptosis  can  easily  be  elicited  by  distending 
the  stomach  with  air  through  a  stomach  tube,  or  by  administering  tartaric 
acid  and  sodium  carbonate  in  separate  doses. 

Treatment. 

The  majority  can  be  greatly  benefited  by  general  treatment,  such  as 
regulating  the  bowels;  massage  of  the  abdomen;  gymnastic  exercises  to 
strengthen  the  abdominal  wall ;  the  avoidance  of  tight  lacing ;  the  administra- 
tion of  tonics ;  giving  a  simple  but  nourishing  diet.  Much  benefit  may  also 
be  derived  by  supporting  the  abdominal  viscera  by  the  wearing  of  a  well- 
fitting  abdominal  support. 

Operative  Treatment. 

Many  operations  have  been  devised  for  holding  up  the  stomach,  but  that 
of  Beyea  seems  to  be  the  most  satisfactory.  He  shortens  the  suspensory 
ligaments  of  the  stomach  without  interfering  with  its  normal  mobility  and 
no  abnormal  attachment  is  made  to  the  abdominal  wall.  The  operation  is 
performed  as  follows  :  A  median  incision  is  made  and  the  patient  placed 
in  the  inverted  Trendelenburg  position,  allowing  the  intestines  to  settle 
toward  the  lower  portion  of  the  abdominal  cavity.  The  sutures  used  should 
be  of  some  non-absorbable  material,  as  linen  or  silk.  The  first  suture  is 
introduced,  beginning  above,  in  the  strong  tissue  of  the  attachment  of  the 
ligament  to  the  liver,  the  needle  grasping  a  considerable  bite  of  tissue,  then 
grasps  the  more  delicate  portion  at  short  intervals  from  above  downwards 
until  a  point  just  above  the  gastric  vessels  is  reached  at  the  lesser  curvature. 
Four  to  six  of  these  sutures  are  inserted  in  this  manner  as  shown  in  illus- 
tration. When  these  sutures  arc  tied  the  lesser  curvature  is  carried  up  in 
contact,  or  almost  in  contact,  with  the  under  surface  of  the  liver  at  the  at- 
tachment of  the  gastrohepatic  ligament,  and  is  fixed  in  this  position. 

The  principle  of  this  operation  is  that  by  placing  interrupted  sutures 
from  above  downward  through  the  gastrohepatic  omentum,  or  gastro- 
hepatic and  gastrophrenic  ligaments,  the  normal  ligamentery  supports  of 
the  stomach  are  shortened  and  the  stomach  elevated  to  its  normal  position 
without  disturbing  the  physiologic  mobility  of  the  organ.  With  the  elevation 
~>f  the  stomach  the  ptosis  of  the  transverse  colon  is  somewhat  corrected. 


6OO  SURGERY    OF    THE    ESOPHAGUS    AND    STOMACH 

After  Treatment. 

After  the  operation  gastric  lavage  should  be  used  once  or  twice  a  day 
during  the  time  the  patient  is  in  the  hospital,  and  nourishment  should  be 
given  in  the  form  of  concentrated  food  in  small  quantities  to  prevent  any 
gaseous  distension  of  the  stomach  until  the  tissues  have  become  firmly  fixed. 
With  the  stomach  in  this  new  position,  the  condition  for  normal  digestion 
will  be  greatly  improved,  and  within  a  few  months  the  patient's  nutrition 
should  be  markedly  better.  Among  these  patients  there  are  many  who 
suffer  from  a  general  neurotic  condition,  and  unless  this  be  due  to  malnu- 
trition resulting  from  the  gastroptosis,  the  neurotic  state  will  not  be  much 
benefited. 


PART   VII. 

SURGERY  OF  THE  GALL  BLADDER  AND 

LIVER. 

In  considering  the  etiology  of  gall  bladder  disease  it  is  important  to  bear 
in  mind  the  anatomical  relation  and  the  mechanical  provisions.  So  long  as 
the  anatomical  relations  are  normal,  and  the  organ  is,  mechanical  con- 
sidered, approximately  perfect,  there  is  no  occasion  for  treatment  because 
the  gall  bladder  becomes  distended  with  bile,  which  is  a  non-irritating  fluid 
and  is  emptied  regularly.  These  functions  give  rise  to  neither  pain,  irrita- 
tion or  discomfort. 

Normally  the  gall  bladder  is  suspended  from  the  under  surface  of  the 
liver  as  a  very  slightly  distended,  pyriform  sac  which  empties  its  fluid  rap- 
idly into  the  duodenum.     The  muscles  of  the  gall  bladder  are  very  active 
and  well  able  to  expel  the  contents. 
Etiology. 

It  seems  to  have  been  proven  beyond  a  doubt  that  this  pouch  shares  the 
fate  of  all  similarly  constructed  organs  in  the  body — the  stomach,  the  urinary 
bladder,  the  pelvis  of  the  kidney,  the  vermiform  appendix ;  so  long  as  there 
is  nothing  to  prevent  these  organs  from  emptying  their  contents  they  are 
almost  certain  to  remain  normal,  but  so  soon  as  obstruction  occurs,  inter- 
fering with  the  natural  drainage  of  the  organ,  trouble  is  likely  to  ensue. 
In  other  words,  an  interference  with  drainage  is  sure  to  cause  a  certain 
amount  of  residual  substance  which  makes  the  accumulation  of  bacteria 
possible,  and  from  this  accumulation  we  must  expect  injury  to  the  lining  of 
the  gall  bladder. 

In  ordinary  health  it  is  probable  that  in  the  majority  of  cases  the  human 
bile  is  sterile.  The  bile  remains  sterile,  however,  only  as  long  as  it  flows 
unobstructed  through  the  ducts.  It  has  been  shown  experimentally  that  as 
soon  as  the  outward  flow  of  bile  has  been  obstructed  by  ligature  of  the 
common  duct,  the  bile  above  the  obstruction  becomes  infected. 

Bacteria  enter  the  gall  bladder  chiefly  in  two  ways:  I.  Along  the  com- 
mon duct  from  the  duodenum.  2.  By  the  blood  current,  chiefly  from  the 
portal  vein.  The  fact  that  the  bacillus  coli  is  the  most  common  bacterial  in- 
habitant of  the  gall  bladder  and  of  gall  stones  suggests  that  an  intestinal 
origin  is  most  probable. 

The  injury  that  results  from  the  accumulation  of  bile  in  the  gall  blad- 
der may  simply  be  catarrhal  at  first,  but  will  later  become  destructive  to  the 
mucous  membrane,  giving  rise  to  ulceration ;  this  in  turn  will  result  in  cica- 
tricial  contraction,  and  this  in  further  obstruction.  In  such  manner  the  con- 
dition must  progress. 

In  the  meantime  the  mucus  and  debris  in  the  gall  bladder  may  have 


6O2 

been  molded  into  gall  stones  by  contraction  of  the  gall  bladder  and  thus 
give  rise  to  another  important  element.  The  lining  of  the  gall  bladder 
is  now  no  longer  in  contact  only  with  the  relatively  non-irritating  bile,  but 
also  with  these  hard  bodies,  which  are  often  of  very  irregular  form,  conse- 
quently having  sharp  angles  or  projections. 

Clinical  experience  has  shown  that  the  above  theory  is  correct,  because 
in  most  of  our  cases  there  has  been  a  distinct  interference  with  drainage 
of  the  gall  bladder.  In  many  cases  this  was  caused  by  a  drawing  down  of 
the  viscus  by  adhesions  to  the  omentum  or  transverse  colon,  or  both,  prob- 
ably caused  by  a  peritonitis  resulting  from  a  perforative  appendicitis  which 
the  patient  had  sustained  many  years  before.  In  other  cases  there  was  a 
pedunculated  gall  bladder,  which  has  been  attributed  to  the  effects  of  tight 
lacing,  and  as  in  many  cases  this  condition  occurred  only  in  women,  it  seems 
possible  that  this  view  is  correct. 

It  has  been  found  that  bacteria,  especially  the  colon  bacillus,  are  present 
with  great  regularity  in  diseased  gall  bladders  and  in  gall  stones.  It  has 
been  found  that  a  large  proportion  of  gall  stone  patients  previously  suffered 
from  typhoid  fever,  and  we  have  found  that  more  than  thirty-five  per  cent 
of  our  cases  suffered  from  acute  or  chronic  appendicitis.  It  is  difficult 
to  determine  whether  typhoid  fever,  disease  of  the  gall  bladder,  and  of  the 
appendix  in  appendicitis,  is  simply  a  simultaneous  infection  or  whether  the 
infection  of  the  gall  bladder  is  secondary  to  the  other  infections. 

In  experiments  upon  animals  it  has  been  found  that  the  simple  infection 
of  the  gall  bladder  gives  rise  to  no  pathological  condition,  provided  there 
is  no  obstruction  to  the  biliary  or  cystic  duct.  The  constant  flow  of  new  bile 
seems  to  be  sufficient  to  dilute  and  wash  away  the  infectious  material  to  a 
sufficient  extent  to  make  the  infection  harmless. 

It  is  quite  different  as  soon  as  there  is  an  obstruction  to  the  ducts. 
Where  there  is  residual  bile  in  which  micro-organisms  can  multiply,  a  path- 
ological condition  will  ensue  which  may  simply  develop  into  a  catarrhal  in- 
flammation of  the  mucous  lining  of  the  gall  bladder,  or  it  may  result  in  the 
formation  of  gall  stones,  or  in  a  severe  inflammation  of  the  gall  bladder  in- 
volving anatomical  structures  beyond  the  mucous  membrane.  In  man  this 
obstruction  may  result  from  the  inflammation  of  the  mucous  membrane  of 
the  common  duct  due  to  an  infection  from  the  alimentary  canal,  or,  as  we 
have  seen  in  a  number  of  cases,  the  gall  bladder  may  be  drawn  downward 
by  adhesions,  causing  a  short  bend  in  the  common  duct,  or  more  usually  in 
the  cystic  duct ;  or  an  adhesion  between  the  duodenum,  stomach  and  liver. 
This  condition  is  often  due  to  a  gastric  or  duodenal  ulcer.  Again,  the  gall 
bladder  may  be  forced  down  out  of  its  normal  position  on  account  of  tight 
lacing,  and  the  mucus  and  debris,  accumulated  in  the  pouch  containing  re- 
sidual bile,  may  be  expelled  at  intervals  and  may  clog  the  biliary  or  the 
common  duct,  and  thus  form  the  obstruction  necessary  to  make  the  infective 
material  effective.  We  have  repeatedly  observed  a  complete  obstruction  of 
the  common  duct  produced  in  this  manner.  Moreover,  we  have  observed 
some  of  the  most  violent  paroxysms  of  gall  stone  colic  in  cases  of  this  kind. 

If  this  obstruction  persists  in  the  presence  of  infectious  material  in.  the 
gall  bladder  a  suppurative  inflammation  may  ensue  and  this  may  result  in 
an  empyema  of  the  gall  bladder ;  if  the  infection  is  severe,  especially  if  there 
be  present  a  spasmodic  contraction  of  the  gall  bladder,  the  entire  mucous  lin- 
ing of  the  latter  may  become  gangrenous,  a  condition  which  we  have  re- 
peatedly seen  in  acute  cases.  This  may  in  turn  extend  to  the  other  layers  of 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  603 

the  gall  bladder,  resulting  in  a  gangrene  of  the  entire  organ,  or  it  may  affect 
only  a  small  portion  of  the  gall  bladder.  When  this  is  the  case,  the  con- 
traction of  the  non-affected  portion  of  the  gall  bladder  is  likely  to  cause  a 
perforation  at  the  gangrenous  point. 

It  is  of  practical  importance  to  know  that  these  spasmodic  contractions 
of  the  gall  bladder  correspond  with  contractions  of  the  stomach  and  that 
they  will  subside  when  the  stomach  is  at  rest,  only  to  recur  when  this  con- 
dition of  rest  in  the  stomach  is  interrupted. 

Age  and  sex  undoubtedly  have  some  influence  upon  the  formation  of 
gall  stones,  most  often  found  in  middle  adult  life.  In  looking  over  a  series 
of  two  hundred  of  our  own  cases  it  was  found  that  the  average  age  at  the 
time  of  operation  was  forty-six  years,  and  that  the  average  duration  of 
symptoms  as  given  in  the  histories  was  six  and  one-half  years.  The  condi- 
tion occurred  four  times  oftener  in  females  than  in  males.  The  youngest 
male  patient  operated  upon  by  the  authors  was  twenty  years  of  age,  and  the 
youngest  female  was  ten  years  old. 

Symptoms  and  Signs  of  Gall  Bladder  Disease. 

The  frequency  with  which  gall  stones  are  overlooked  draws  our  atten- 
tion to  the  fact  that  it  will  be  necessary  to  change  the  basis  of  our  diagnosis, 
because  the  old  plan  must  continue  to  result  in  wrong  conclusions. 

In  studying  the  histories  of  a  series  of  gall  stone  cases  it  will  be  found 
that  the  early  manifestations  of  the  presence  of  gall  stones  will  practically 
never  be  referred  by  the  patient  to  the  region  of  the  gall  bladder  or  bile 
ducts.  The  patients  refer  their  trouble  to  the  region  of  the  stomach  and 
not  to  the  liver. 

Perhaps  the  earliest  symptom,  which  has  persisted  for  years,  is  "indi- 
gestion." It  is  not  uncommon  for  these  patients  to  come  to  the  surgeon 
with  a  diagnosis  of  an  attack  of  indigestion,  gastric  catarrh,  neuralgia  of 
the  stomach,  spasms,  etc. 

The  symptoms,  complications  and  dangers  of  gall  stones  differ  greatly 
according  to  the  location  of  the  stones  in  the  gall  bladder,  cystic  or  common 
ducts. 

Gall  stones  in  the  gall  bladder,  in  the  absence  of  infection,  may  produce 
so  little  discomfort  that  they  may  persist  for  years  without  being  discov- 
ered. As  soon  as  catarrh  or  some  acute  infection  occurs,  or  the  stone  passes 
from  the  gall  bladder  into  the  cystic  duct,  there  may  be  a  great  variety  of 
symptoms,  varying  from  mere  spasms,  frequently  called  attacks  of  "indi- 
gestion," to  very  severe  colic,  agonizing  in  character,  so  severe  as  to  even 
lead  to  collapse. 

Pain  to  be  distinguished  from  colic,  may  be  local  or  referred.  The 
local  pain  may  be  dull  in  character  rather  diffuse,  and  exaggerated  upon  tak- 
ing food.  It  is  this  variety  of  pain  which  is  apt  to  be  mistaken  for  that  due 
to  disease  of  the  stomach.  The  dull  pain  is  usually  due  to  some  irritation 
or  inflammation  of  the  gall  bladder  becoming  more  or  less  tense  by  some 
obstruction  to  the  cystic  duct  due  to  an  impaction  of  a  stone  in  the  cystic 
duct  in  its  attempt  to  escape  from  the  gall  bladder,  or  to  an  inflammatory 
state  of  the  gall  bladder  interfering  with  the  free  exit  of  bile. 

An  Important  Sign. 

Tenderness  is  always  present  especially  on  deep  pressure.  One  of  the 
most  constant  signs  of  gall  bladder  disease  is  the  inability  of  the  patient  to 
take  a  full  inspiration  when  the  physician's  fingers  are  placed  up  under- 


604  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

neath  the  costal  arch  in  the  region  of  the  ninth  or  tenth  ribs.  The  dia- 
phragm forces  the  liver  down  until  the  sensitive  gall  bladder  reaches  the 
examining  fingers  when  the  inspiration  suddenly  ceases  as  though  it  had 
been  shut  off. 

The  pain  is  frequently  more  acute  than  that  described  above,  which 
means  that  there  is  a  more  marked  irritation  and  inflammation  of  the  gall 
bladder  or  its  ducts,  and  perhaps  of  the  surrounding  peritoneum. 

The  pain  may  be  referred  to  various  regions.  It  frequently  radiates  to 
the  right  subscapular  region  and  occasionally  to  the  left;  to  the  epigastric 
region  or  umbilicus ;  to  the  front  of  the  chest  and  neck  or  down  the  arm. 

Boas  has  described  the  existence  of  an  area  of  referred  tenderness 
which  is  present  in  the  majority  of  patients  suffering  from  gall  bladder 
disease. 

To  demonstrate  this  area  the  finger  should  be  pressed  against  a  point 
to  the  right  of  the  tenth  dorsal  spine ;  then  against  successive  points  in  lines 
running  horizontally  outwards,  opposite  the  other  spinous  processes.  It  will 
then  be  evident  which  side,  if  either,  is  the  more  tender. 

Colic  in  gall  stone  disease  is  not  as  common  as  formerly  supposed.  We 
have  found  that  over  one-half  of  our  cases  have  never  experienced  severe 
biliary  colic. 

The  colic,  when  severe,  causes  the  most  intense  suffering.  It  comes 
on  suddenly  and  not  infrequently  produces  a  condition  of  collapse.  The 
patient  is  cold  and  yet  has  profuse  sweating. 

The  location  of  the  pain  differs  greatly.  When  the  colic  is  due  to  a 
spasm  of  the  gall  bladder  or  cystic  duct  it  is  most  apt  to  begin  along  the 
right  costal  margin  and  radiate  to  the  right  subscapular  region.  When  due 
to  spasm  of  the  common  duct  it  is  more  apt  to  be  located  centrally  and 
radiate  to  the  mid-scapular  region.  It  may  be  epigastric  throughout,  or  may 
even  be  situated  in  the  left  upper  quadrant  of  the  abdomen. 

The  cause  of  gall  stone  colic  has  been  much  discussed,  yet  there  seems 
to  be  no  present  agreement  upon  this  subject. 

Considering  the  abruptness  with  which  these  colics  begin,  and  the  sud- 
denness in  their  relief,  it  would  seem  more  probable  that  the  pain  was  due 
to  a  spasm  of  the  gall  bladder  or  its  ducts  during  the  attempt  at  expulsion 
of  a  calculus,  or  of  thick  bile,  sand  or  mucus.  This  suddenness  with  which 
the  pain  begins  and  subsides  is  certainly  incompatible  with  anything  of  an 
inflammatory  nature,  and  can  only  be  explained  by  a  spasm  due  to  the  sudden 
entrance  and  exit  of  some  foreign  body. 

It  is  of  practical  interest  to  know  that  these  spasmodic  contractions  of 
the  gall  bladder  correspond  with  the  contraction  of  the  stomach  and  that 
they  will  subside  when  the  stomach  is  at  rest,  only  to  recur  when  this  con- 
dition of  rest  in  the  stomach  is  interrupted. 

We  have  repeatedly  observed  that  attacks  of  gall  stone  colic,  which 
would  not  subside  from  the  use  of  as  much  as  one-half  to  three-quarters  of 
a  grain  of  morphine  given  hypodermically,  stop  directly  upon  irrigating 
the  stomach  with  very  hot  water,  thus  putting  the  organ  at  rest,  only  to 
have  a  recurrence  the  moment  any  form  of  food  was  taken  into  the  stomach 
giving  rise  to  the  normal  contraction  thereof.  In  these  cases  a  renewed 
use  of  gastric  lavage  and  further  abstaining  from  food,  would  result  in 
permanent  interruption  of  the  spasmodic  contraction  of  the  gall  bladder. 
This  point  is  of  practical  importance,  because  it  not  only  indicates  an  efficient 
means  for  securing  the  relief  of  pain,  but  also  for  preventing  destruction  of 
gall  bladder  tissue  and  possible  perforation. 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  605 

Stomach  Symptoms. 

Perhaps  the  most  common  symptom  of  gall  stone  disease  is  "indiges- 
tion." The  attacks  of  indigestion  begin  with  pain  in  the  epigastrium,  fol- 
lowed by  nausea  and  finally  vomiting,  which  usually  brings  relief.  The 
nausea  and  comiting  are  partly  reflex  in  character  and  partly  due  to  direct 
irritation. 

Other  gastric  disturbances  associated  with  gall  bladder  disease  are 
frequently  manifested  by  distress  in  the  epigastric  region,  described  as  a 
feeling  of  weight  or  a  burning  sensation  after  eating ;  also  gaseous  dis- 
tension of  the  abdomen.  These  patients  are  also  usually  troubled  with 
eructations  of  gas  after  eating.  It  is  not  uncommon  for  these  patients  to 
have  repeated  attacks  of  nausea  and  vomiting  and  attacks  of  indigestion 
accompanied  by  a  severe  pain  in  the  epigastrim  often  called  gastralgia  or 
neuralgia  of  the  stomach. 

After  an  attack  of  nausea,  vomiting  and  epigastric  pain  there  is  apt  to 
be  an  interim  when  the  patient  is  free  from  stomach  symptoms,  or  has  only 
the  milder  symptoms  of  bloating  and  distress  after  eating. 

There  may  be  a  dull  pain  beginning  in  the  epigastric  region  and  extend- 
ing around  the  right  side  at  about  the  level  of  the  tenth  rib,  passing  to  a 
point  near  the  spine  and  progressing  upwards  underneath  the  right  shoulder 
blade. 

Jaundice. 

Jaundice,  upon  which  so  much  stress  has  been  placed  in  the  diagnosis 
of  gall  stones,  is  absent  in  the  greater  number  of  cases.  Our  experience  has 
been  that  only  a  small  proportion  of  cases  have  ever  been  severely  jaundiced, 
and  in  more  than  one-half  of  them  jaundice  has  never  been  observed. 

The  symptoms  in  regard  to  icterus  in  connection  with  gall  stones  has 
been  handed  down  to  successive  generations  of  physicians  and  the  laity  so 
long,  that  the  majority  of  patients  refuse  to  believe  that  they  could  have  gall 
stones  and  not  be  jaundiced. 

Jaundice  in  cholelithiasis  is  due  to  an  impaction  of  a  stone  in  the  com- 
mon or  hepatic  ducts,  or  an  infection  of  these  ducts,  and  occasionally  to  an 
impaction  of  a  large  stone  in  the  cystic  duct  pressing  upon  the  common  or 
hepatic  ducts. 

When  jaundice  is  due  to  gall  stones  it  is  most  always  preceded  by  a 
colic.  The  colic  may  come  on  a  few  hours  or  days  before  the  appearance  of 
the  jaundice.  The  yellow  tinge  as  a  rule  comes  on  gradually  and  increases 
until  the  obstruction  is  relieved,  and  then  gradually  disappears. 

Remittent  icterus,  slight,  or  as  might  be  called,  incomplete  attacks  of 
icterus,  occurring  as  often  as  once  or  twice  a  week,  is  characteristic  of  stone 
in  the  common  duct.  Fenger  attributed  this  condition  to  a  floating  chole- 
dochus-stone.  He  described  this  condition  as  occurring  in  the  following 
manner :  A  stone  becomes  impacted  in  the  common  duct,  and  the  accumu- 
lation of  bile  on  the  proximal  or  liver  side,  presses  the  walls  of  the  duct 
away  from  the  stone,  allowing  the  bile  to  pass  around  the  stone.  Following 
this  the  remittent  jaundice  is  due  to  a  "ball-valve"  action  of  the  stone. 

When  jaundice  is  due  to  a  carcinoma  involving  the  gall  ducts,  or  from 
pressure  from  a  growth  of  the  head  of  the  pancreas,  the  jaundice  will  appear 
gradually  and  without  pain.  There  will  be  no  remission  or  intermission,  but 
will  steadily  deepen  from  day  to  day  until  the  skin  becomes  a  greenish- 
yellow  color.  It  is  very  rare  to  meet  with  jaundice  of  a  deep  greenish-yellow 
color,  except  in  the  presence  of  malignant  disease. 


606  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

Fever. 

Fever  is  not  ordinarily  present  early  in  a  simple  attack  of  gall  stones. 
If  the  attack  is  prolonged  and  infection  occurs,  temperature  develops.  When 
the  infection  is  confined  entirely  to  the  gall  bladder,  the  rise  of  temperature 
is  usually  not  high.  Mayo  explains  this  condition  by  the  fact  that  there  are 
few  lymphatic  channels  in  the  gall  bladder  and  consequently  slow  absorption. 

Where  there  is  an  infection  of  the  ducts  there  may  be  rigor  accom- 
panying or  following  the  colic,  with  a  very  abrupt  rise  of  temperature  to  its 
maximum,  and  then  with  almost  equal  rapidity  return  to  normal.  These 
attacks  may  simulate  a  malarial  infection.  Between  the  attacks  of  infection 
the  temperature  remains  practically  normal.  Persistent  fever  associated  with 
other  gall  stone  symptoms  may  mean  an  empyema,  or  severe  cholecystitis 
or  an  extension  of  the  infection  to  the  channels  in  the  liver. 

Tumor. 

A  palpable  enlargement  of  the  gall  bladder  occurs  as  the  result  of  some 
obstruction  of  the  cystic  duct.  This  obstruction  may  be  from  an  impacted 
stone,  a  cicatricial  contraction  of  the  cystic  duct,  a  twist  of  the  neck  of  the 
gall  bladder,  or  from  an  abnormal  growth.  It  occurs  also  when  there  is 
an  obstruction  of  the  common  duct  caused  by  some  pressure  from  outside. 

An  enlarged  gall  bladder  is  generally  pear-shaped,  lies  just  below  the 
edge  of  the  liver  and  moves  up  and  down,  during  the  act  of  respiration,  with 
the  liver. 

OBSTRUCTION    OF    THE    CYSTIC  DUCT. 

Obstruction  of  the  cystic  duct  causes  retention  of  fluid  in  the  gall  blad- 
der with  a  rapid  distension  thereof  behind  the  obstruction.  This  fluid  con- 
sists of  mucus  if  the  infection  is  slight,  or  of  muco-pus  if  the  infection  is 
more  severe.  The  bile  that  may  be  in  the  gall  bladder  at  the  time  the  ob- 
struction occurs,  is  rapidly  absorbed,  leaving  either  the  clear  mucus  or  turbid 
fluid,  according  to  the  amount  of  infection.  The  distended  gall  bladder 
may  reach  an  enormous  size  and  usually  becomes  palpable.  If  the  inflam- 
matory process  be  very  acute  a  severe  cholecystitis  or  even  gangrene  of  the 
gall  bladder  may  result.  Associated  with  this  condition  a  local  protective 
peritonitis  usually  develops  leading  to  the  formation  of  visceral  adhesions. 

The  early  symptoms  of  impaction  of  stone  in  the  cystic  duct  are  usually 
very  acute,  beginning  with  a  severe  colic  underneath  the  right  costal  arch, 
and  radiating  up  into  the  right  subscapular  region.  There  is  rarely  any 
jaundice  accompanying  or  following  the  pain.  The  pain  loses  its  colicky 
character  rather  early  and  there  may  be  only  a  dull  ache  or  sense  of  discom- 
fort. If  the  obstruction  becomes  chronic  and  there  is  little  or  no  infection, 
a  hydrops  of  the  gall  bladder  develops.  If  it  is  associated  with  infection  of 
any  severity,  an  empyema  of  the  gall  bladder  is  apt  to  be  the  result. 

All  of  these  symptoms  may  occur  without  any  evidence  of  jaundice. 

ACUTE    CHOLECYSTITIS. 

The  symptoms  found  in  an  acute  cholecystitis  are  similar  to  those 
present  in  the  early  stage  of  cholelithiasis.  In  addition  to  these  there  is  an 
enlargement  of  the  gall  bladder,  often  making  it  palpable  and  very  tender 
upon  pressure.  There  is  often  acute,  severe  pain  in  the  gall  bladder  which 
may  radiate  to  the  back,  chest  or  abdomen.  Associated  with  the  pain  and 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  607 

tenderness  there  may  be  a  right-sided  rigidity  which  may  simulate  appendi- 
citis. The  history  will  help  in  the  diagnosis,  as  it  will  be  found  that  the  pain 
was  originally  in  the  gall  bladder  region  and  later  became  diffused.  iAs  a 
rule  the  tenderness,  pain  and  rigidity  of  the  abdomen  are  limited  to  an  area 
along  the  costal  margin. 

CHRONIC   CHOLECYSTITIS. 

In  chronic  cholecystitis  there  is  seldom  present  a  definite  train  of  symp- 
toms which  would  ordinarily  direct  one's  attention  to  the  gall  bladder. 
However,  there  is  usually  present  a  rather  constant  dull,  aching  pain  in  the 
right  hypochondrium,  often  hardly  noticeable.  There  may  be  exacerbations 
of  the  inflammatory  trouble  when  the  pain  will  be  more  marked.  The  prin- 
cipal symptoms  will  be  in  the  line  of  digestive  disturbances,  manifested  by 
sensation  of  fullness  in  the  epigastrium,  more  or  less  bloating  and  distress 
coming  on  during  or  immediately  after  eating,  accompanied  by  eructations 
of  gas.  It  is  not  uncommon  for  these  patients  to  complain  of  "sour" 
stomach. 

Occasionally  these  cases  will  suffer  from  a  typical  attack  of  biliary  colic 
from  the  passage  of  sand-like  material  through  the  gall  ducts.  It  is  not 
uncommon  in  cases  of  chronic  cholecystitis  to  find  the  gall  bladder  filled  with 
black,  thick,  sandy  bile. 

The  diagnosis  depends  upon  the  various  gastric  disturbances  enumer- 
ated above,  together  with  the  dull  aching  or  burning  pain  in  the  right  hypo- 
chondrium, and  the  finding  of  an  area  of  tenderness  in  the  region  of  the  gall 
bladder.  This  tenderness  is  practically  always  present  and  can  be  elicited  by 
placing  the  finger-tips  underneath  the  costal  arch,  and  when  the  abdominal 
muscles  are  relaxed,  have  the  patient  take  a  deep  full  inspiration  forcing  the 
gall  bladder  against  the  finger-tips. 

STONES   IN   THE    COMMON    DUCT. 

With  stones  in  the  common  duct  it  is  not  uncommon  to  find  a  history 
of  frequent  attacks  of  pain  which  have  occurred  at  variable  intervals  for 
years,  accompanied  by  a  slight  jaundice.  Suddenly  there  will  be  an  attack 
of  severe  pain  with  a  rapid  and  pronounced  jaundice.  This  is  the  time  at 
which  the  stone  passes  into  the  common  duct.  If  the  stone  be  a  small  one 
it  may  pass  on  into  the  intestine  and  the  jaundice  entirely  clear  up  in  a  few 
days.  If  the  stone  becomes  impacted  in  the  common  duct  there  will  be  a 
complete  obstruction  to  the  passage  of  bile,  resulting  in  severe  jaundice  and 
enlargement  of  the  liver. 

It  is  rare  to  meet  with  an  acute  permanent  occlusion  of  the  common 
duct  from  stone.  As  soon  as  the  stone  becomes  impacted,  the  pressure  of 
the  bile  causes  a  dilatation  of  the  duct  so  that  a  stone  which  at  first  fits  tightly 
will  be  loose  in  the  duct,  allowing  the  bile  to  pass  around  it.  We  then  have  a 
condition,  which  Fenger  described,  of  the  stone  acting  as  a  "ball-valve"  in 
the  duct,  which  then  gives  a  characteristic  history  of  chronic  common  duct 
stone ;  frequent  attacks  of  pain  occurring-  once  or  twice  a  week,  accom- 
panied by  slight  rigor  and  temperature  of  101°,  with  or  without  noticeable 
jaundice.  In  practically  all  of  these  cases  close  inspection  will  reveal  the 
presence  of  slight  icterus. 

In  many  patients  with  an  obstruction  of  the  common  duct  there  is  a  con- 


608  SURGERY    OI'    THE    GALL    BLADDER    AND    LIVER 

siderable  loss  in  weight.  It  is  important  to  bear  this  point  in  mind,  as  a 
symptom  of  stone  in  the  common  duct.  The  rapid  loss  of  weight  is  very 
apt  to  suggest  a  diagnosis  of  malignant  disease. 

The  jaundice  of  malignant  disease  is  not  accompanied  by  pain,  it  steadily 
increases  and  does  not  vary  from  day  to  day,  as  it  usually  does  in  common 
duct  stones.  When  the  jaundice  is  due  to  some  pressure  from  outside  the 
duct,  as  a  carcinoma  of  the  head  of  the  pancreas,  the  gall  bladder  will  be 
distended,  while  in  cases  where  the  obstruction  is  from  a  stone  within  the 
duct  the  gall  bladder  is  usually  contracted. 
Indications  for  Operation. 

So  long  as  the  gall  stones  simply  remain  in  the  gall  bladder  without 
causing  any  complications,  the  harm  to  the  patient  is  relatively  slight.  The 
patient's  comfort  will  be  greatly  disturbed  on  account  of  the  disturbances  of 
digestion.  The  pain  will  not  be  extreme  and  he  usually  accumulates  an 
abundance  of  fat,  especially  in  the  abdominal  walls.  It  has  consequently  been 
held  by  many  authorities  that  it  is  not  wise  to  make  use  of  radical  measures 
for  the  removal  of  gall  stones  so  long  as  they  do  not  give  rise  to  any  grave 
disturbances.  This  undoubtedly  would  be  a  proper  and  reasonable  view  to 
take  were  the  danger  to  the  patient  approximately  the  same  before  and  after 
the  occurrence  of  these  complications.  This,  however,  is  not  the  case.  Ex- 
perience has  shown  us  that  the  mortality  in  cases  which  are  operated  before 
any  serious  complications  arise  is  practically  nil,  while  the  deaths  that  happen 
in  the  complicated  cases  undoubtedly  might  have  been  saved  had  the  opera- 
tion been  performed  before  these  complications  arose. 

It  was  the  mortality  and  complications  of  delay  that  placed  the  early 
and  interval  operation  for  appendicitis  on  a  sound  surgical  footing.  To 
remove  the  disease  while  still  in  the  appendix  and  avoid  the  various  compli- 
cations was  a  logical  conclusion.  The  same  reason  applies  with  equal  force 
to  the  early  operation  for  gall  stone  disease.  Remove  the  disease  while  still 
in  the  gall  bladder. 

The  complications  which  are  likely  to  be  caused  by  the  presence  of  gall 
stones  may  be  chronic  in  character,  taking  the  form  of  digestive  disturbances 
and  giving  rise  to  almost  constant  discomfort.  This  is  probably  due  to  the 
interference  of  the  passage  of  food  through  the  pylorus  into  the  doudenum, 
causing  dilatation  of  the  stomach. 

Again,  the  patient  may  be  in  a  slightly  septic  condition,  because  there 
is  more  or  less  absorption  of  the  septic  material  from  the  infected  residual 
bile,  as  well  as  from  the  products  of  fermentation  in  the  dilated  stomach. 
These  conditions  frequently  result  in  chronic  invalidism,  making  it  impossible 
for  the  patient  to  follow  ordinary  occupations  and  to  enjoy  life  in  any  way. 
The  constant  irritation  of  the  gall  bladder,  due  to  the  pressure  of  the  gall 
stones,  undoubtedly  has  much  to  do  with  the  development  of  carcinoma  in 
this  organ. 

In  cases  of  primary  carcinoma  of  the  gall  bladder,  we  have  always  been 
able  to  get  a  history  of  gall  stones  dating  back  many  years,  and  have  invari- 
ably found  these  present  in  the  gall  bladder  in  such  instances  at  the  time  of 
the  operation  or  autopsy.  Aside  from  these  chronic  affections  gall  stones 
may  at  any  time  cause  exceedingly  grave  acute  conditions. 
Complications  and  Sequelae. 

These  complications  are  all  the  result  of  inflammation  and  the  sequelae 
must  consequently  depend  upon  the  extent  to  which  this  develops. 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  609 

We  take  the  following  list  of  complications  from  Mayo  Robson's  excel- 
lent article  on  this  subject,  because  its  arrangement  is  most  satisfactory: 

1.  Ileus  due  to  paresis  of  the  bowel,  leading  to  enormous  distension 
of  the  abdomen  and  to  symptoms  and  appearances  of  acute  intestinal  obstruc- 
tion, apparently  the  consequence  of  the  violent  pain. 

2.  Acute  intestinal  obstruction  dependent  on 

(a)  Paralysis  of  gut  due  to  local  peritonitis  in  the  neighborhood  of 
the  gall  bladder. 

(b)  Volvulus  of  small  intestine. 

(c)  Stricture  of  intestine  by  adventitious  bands,  originally  pro- 
duced as  a  result  of  gall  stones. 

(d)  Impaction  of  a  large  gall  stone  in  same  part  of  the  intestine 
after  ulcerating  its  way  from  the  bile  channels  into  the  bowels. 

3.  General  hemorrhage,  the  result  of  long-continued  jaundice,  depend- 
ent either  on  gall  stones  alone,  or  on  cholelithiasis  associated  with  malignant 
disease  or  with  intestinal  pancreatitis. 

4.  Localized  peritonitis,  producing  adhesions  which  may  then  become 
a  source  of  pain  even  after  the  gall  stones  have  been  gotten  rid  of.     It  is 
believed  that  nearly  every  serious  attack  of  biliary  colic  is  accompanied  by 
adhesive  peritonitis,  as  experience  shows  that  adhesions  are  found  practically 
in  all  cases  where  there  have  been  characteristic  seizures. 

5.  Dilatation  of  stomach  depending  upon  adhesions  around  the  pylorus. 

6.  Ulceration  of  the  bile  passages,  establishing  a  fistula  between  them 
and  the  intestine. 

7.  Stricture  of  the  cystic  or  common  duct. 

8.  Abscess  of  the  liver. 

9.  Localized  peritoneal  abscess. 

10.  Abscess  in  the  abdominal  wall. 

n.     Fistula  at  the  umbilicus,  or  elsewhere  on  the  surface  of  the  ab- 
domen, discharging  mucus,  muco-pus,  or  bile. 

12.  Empyema  of  the  gall  bladder. 

13.  Infective  and  suppurative  cholangitis. 

14.  Septicemia  or  pyemia. 

15.  Phlegmonous  cholecystitis. 

1 6.  Gangrene  of  the  gall  bladder. 

17.  Perforative  peritonitis  due  to  ulceration  through  or  to  rupture  of 
the  gall  bladder  or  ducts,  leading  to  extravasation  of  infected  bile  into  the 
general  peritoneal  cavity. 

18.  Pyelitis  on   the   right  side   due   to   a  gall   stone   ulcerating  or   an 
abscess  of  the  gall  bladder  bursting  into  the  pelvis  of  the  kidney. 

19.  Cancer  of  the  gall  bladder  or  ducts. 

20.  Subphrenic  abscess. 

21.  Pleurisy  or  empyema  of  the  right  pleura. 

22.  Pneumonia  of  lower  lobe  of  right  lung. 

23.  Chronic  invalidism  or  inability  to  perform   any   of   the  ordinary 
business  or  social  duties  of  life. 

24.  Gangrenous  or  suppurative  pancreatitis. 

25.  Chronic    interstitial   pancreatitis. 

26.  Infective  endocarditis. 

27.  Cirrhosis  of  liver. 

28.  Appendicitis    due    to    extension    of    inflammation    from    the    gall 
bladder  or  to  impaction  of  a  gall  stone  in  the  appendix. 


SlO  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

Contraindications  to  Operation. 

In  disease  of  the  gall  bladder  there  are  some  definite  contraindications 
to  operation  which,  it  is  believed,  have  now  been  quite  thoroughly  estab- 
lished by  clinical  observation. 

1.  It  is  ordinarily  unwise  to  operate  during  the  attack  of  gall  stone 
colic. 

2.  Severe  icterus  is  a  contraindication  to  a  prolonged  operation. 

?.     The  same  is  true  of  prostration  following  long-continued  suffering. 

4.  Cases  complicated  with  carcinoma  belong  to  the  same  class. 

5.  Patients  with  ecchymotic  spots  are  almost  certain  to  die  if  operated. 
In  all  these  cases  if  an  operation  must  be  performed  it  should  be  limited 

to  drainage  of  the  gall  bladder  and  removal  of  the  stones  in  this  viscus, 
and  all  further  manipulations  should  be  postponed  until  the  patient  is  in  a 
better  general  condition. 

Treatment, 

Gall  stones  and  severe  infections  of  the  bile  tracts  have  come  to  be 
looked  upon  as  purely  surgical  affections.  However,  it  has  been  our  ex- 
perience that  cases  with  acute  exacerbations  fare  better  if  the  operation  is 
deferred  until  the  acute  symptoms  have  subsided.  In  any  case  complicated 
with  an  acute  inflammatory  condition,  we  believe  that  the  same  general  prin- 
ciple should  be  employed  in  the  treatment  of  this  condition  as  inflamma- 
tory processes  involving  the  peritoneum  from  any  other  cause.  So  long  as 
there  is  no  circumscribed  accumulation  of  pus,  the  treatment  must  consist 
in  rest.  This  can  be  secured  most  readily  by  using  gastric  lavage  in  order 
to  remove  remnants  of  food  or  decomposing  mucus  from  the  stomach,  then 
prohibiting  the  use  of  cathartics  and  food  by  mouth. 

We  desire  especially  to  emphasize  the  value  of  securing  absolute  rest 
of  the  stomach  by  the  use  of  gastric  lavage,  and  then  not  placing  any  form 
of  nourishment  in  the  stomach  but  confining  the  patient  to  exclusive  rectal 
alimentation,  in  the  treatment  of  patients  suffering  from  acute  cholecys- 
titis characterized  by  the  presence  of  severe  gall  stone  colic.  We  have  seen 
many  cases  where  the  pain  was  excruciating  and  large  doses  of  morphine 
given  hypodermically  failed  to  give  relief,  in  whom  the  pain  disappeared 
almost  completely  without  further  opiates  after  the  use  of  gastric  lavage. 
In  these  cases  the  pain  does  not  recur  unless  some  form  of  nourishment  is 
given  by  mouth ;  even  water  often  causes  recurrence  of  pain. 

It  may  be  difficult  to  explain  this  observation,  but  it  is  likely  that  the 
presence  of  even  a  small  amount  of  food  or  mucus  in  the  stomach  will  be 
forced  into  the  duodenum  and  that  when  it  passes  over  the  entrance  of  the 
common  duct,  it  causes  a  contraction  of  the  gall  bladder  and  this  excites  the 
pain. 

The  use  of  moist  heat  in  the  form  of  poultices  or  fomentations,  or  of 
cold  by  means  by  an  ice  bag,  give  the  patient  great  comfort  and  is  undoubt- 
edly beneficial. 

Morphia  may  be  given  hypodermically  if  necessary,  but  so  long  as 
neither  food  nor  carthartics  are  given  by  mouth  the  pain  usually  subsides 
rapidly  and  permanently.  Nourishment  may  be  supplied  by  enema  not 
oftener  than  once  in  four  hours,  nor  in  larger  quantities  than  four  ounces 
at  a  time.  We  prefer  for  this  purpose  one  of  the  various  reliable  predi- 
gested  foods  mixed  with  three  ounces  of  warm  normal  salt  solution.  In 
many  cases  we  give  no  nourishment  solution  at  all,  and  instead  give  con- 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  6ll 

tinuous  salt  solution  per  rectum  by  the  drop  method.  Unless  the  acute  con- 
dition is  complicated  by  a  mechanical  obstruction  of  the  intestines,  the  pa- 
tient's chances  for  recovery  from  the  acute  attack  is  far  better  without  than 
with  an  operation. 

It  is  necessary  to  make  a  definite  distinction  between  intestinal  obstruc- 
tion due  to  peritonitis  and  that  due  to  a  mechanical  condition,  such  as  the 
impaction  of  a  gall  stone.  The  former  is  so  much  more  common  than  the 
latter  that  it  is  only  very  seldom  the  latter  need  be  considered.  Mechanical 
obstruction  due  to  impaction  of  a  gall  stone  is  characterized  by  the  sudden 
onset  of  symptoms  of  an  acute  intestinal  obstruction,  without  the  inflamma- 
tory symptoms  which  must  be  present  if  it  was  due  to  a  peritonitis. 

When  the  patient  has  recovered  from  his  acute  attack  the  further  treat- 
ment may  be  conducted  medically,  which  will  not  cure  but  may  improve  his 
condition  very  greatly,  or  surgically  which  is  likely  to  result  in  a  perfect 
permanent  recovery. 

The  medical  treatment  must  consist  chiefly  in  the  use  of  large  quantities 
of  water,  preferably  taken  hot,  and  in  the  use  of  a  diet  fairly  free  from  sugar 
and  starch. 

We  believe,  however,  that  the  greatest  benefit  comes  from  drinking  a 
great  amount  of  good  water  and  never  eating  quite  enough  to  satisfy  the 
hunger,  and  from  taking  vigorous  out-of-door  exercise,  such  as  horse-back 
riding,  walking  or  rowing.  Sodium  phosphate  in  doses  of  one  drachm  or 
more,  in  a  large  goblet  of  hot  water,  half  an  hour  before  each  meal,  and 
pure  olive  oil  in  doses  of  one-half  to  four  ounces,  at  bed  time,  seems  to  have 
given  relief  to  patients  suffering  from  gall  stones,  many  of  them  remaining 
free  from  severe  attacks  for  a  long  period  of  time  by  conjoining  these 
remedies  with  proper  diet  and  exercise. 

Whether  the  relief  is  due  to  the  fact  that  in  this  manner  constipation 
is  prevented  and  elimination  facilitated  by  the  large  draughts  of  hot  water, 
or  whether  there  is  some  special  virtue  in  the  remedies,  it  is  difficult  to  say. 
That  many  of  the  patients  are  relieved  of  their  gall  stone  colics  upon  fol- 
lowing this  plan  of  treatment,  there  can  be  no  doubt. 

It  is  plain,  however,  that  this  form  of  treatment  can  be  of  benefit  only 
to  a  limited  number  of  patients,  namely,  those  in  whom  there  is  no  impac- 
tion of  the  gall  stones  in  the  gall  bladder,  or  in  the  common  or  cystic  duct, 
and  which  are  not  complicated  by  serious  lesions  of  any  portion  of  the 
mucous  membrane  lining  these  parts,  or  with  extensive  adhesions.  More- 
over, these  patients  are  apt  to  have  recurrences  with  one  or  more  of  the 
complications  enumerated  above.  Aside  from  this  there  is  always  the 
danger  of  the  development  of  carcinoma  as  a  result  of  the  long-continued 
irritation. 

Of  late  it  has  been  our  practice  to  advise  the  removal  of  stones  in  all 
cases,  provided  the  patient's  general  condition  would  warrant  such  an 
operation,  and  to  carry  out  the  palliative  measures  as  described  above  only 
in  cases  that  refused  operation. 

Technique. 

In  operations  on  the  gall  bladder  and  especially  those  upon  the  bile 
ducts,  considerable  advantage  may  be  gained  by  placing  a  sand  bag  at  or 
under  the  patient's  back  at  or  a  little  above  the  level  of  the  liver.  This 
will  cause  the  liver  to  present  in  the  wound  and  afford  easy  access  to  the 
cystic  and  common  ducts. 

For  all  gall  bladder  operations,  a  straight  incision  made  through  the 


6l2  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

right  rectus  muscle,  near  its  outer  border,  is  undoubtedly  the  best,  primarily. 
The  upper  end  of  the  incision  starts  at  the  costal  margin  and  extends  down- 
ward. The  incision  is  first  carried  through  the  skin,  superficial  and  deep 
fascia  down  to  the  muscle  fibres. 

These  should  be  separated  longitudinally,  by  means  of  a  blunt  instru- 
ment like  the  handle  of  a  scalpel,  so  that  none  of  the  fibres  shall  be  cut. 
The  incision  is  completed  by  carrying  it  through  the  transversalis  fascia 
and  the  peritoneum.  The  wound  should  be  long  enough  to  admit  the  entire 
hand,  as  advised  by  Maurice  Richardson.  This  is  important  because  the 
next  step  must  consist  in  a  careful  palpation  of  the  gall  bladder,  the  cystic, 
the  hepatic  and  the  common  ducts.  This  cannot  be  done  thoroughly  without 
introducing  the  entire  hand. 

The  pancreas,  duodenum  and  the  pylorus  should  be  examined  at  the 
same  time. 

The  various  incisions  used  in  operations  upon  the  gall  tract  are  illus- 
trated in  Figs.  3  and  4. 

Should  it  be  found  that  more  room  is  needed  than  the  rectus  incision 
gives,  it  may  be  obtained  by  carrying  the  upper  end  of  the  incision  upwards 
and  inwards,  cutting  the  rectus  fibres  about  one  inch  from  the  costal  margin 
which  virtually  converts  our  primary  rectus  incision  into  one  first  suggested 
by  Mayo  Robson.  Or  this  rectus  incision  may  be  converted  into  the  "S" 
shaped  incision  as  devised  by  Bevan.  It  is  rare  though  that  there  will  be 
need  for  any  other  than  the  straight  rectus  opening. 

CHOLECYSTOTOMY. 

Cholecystotomy  is  the  operation  of  choice  for  removal  of  stones  from 
the  gall  bladder. 

Cholecystotomy  is  further  performed  for  the  purpose  of  establishing 
drainage  of  the  gall  bladder,  which  is  useful  in  not  only  relieving  irritation 
of  the  gall  bladder  and  biliary  ducts,  but  indirectly  it  seems  to  drain  the  liver 
and  the  pancreas  and  as  a  result  of  this  drainage  these  organs,  when  gen- 
erally enlarged  as  a  result  of  chronic  inflammation  or  irritation  due  to 
faulty  drainage,  will  decrease  in  size  very  rapidly. 

It  is  consequently  important  to  determine  these  conditions  before  de- 
ciding upon  the  operation  to  be  chosen  in  any  given  case.  After  making 
the  incision,  the  hand  is  introduced  into  the  abdominal  cavity  and  the  gall 
bladder  is  palpated  between  the  finger  and  thumb.  It  is  then  followed  down- 
ward and  inwards  and  the  cystic,  hepatic  and  common  ducts  are  palpated 
in  succession. 

Occasionally  the  gall  bladder  may  be  so  tense  that  nothing  can  be  de- 
termined concerning  the  character  of  its  contents,  except  that  whatever  the 
gall  bladder  may  contain  it  is  impossible  for  this  substance  to  pass  on  freely 
into  the  duodenum,  and  this,  in  itself,  is  the  strongest  indication  for  a 
Cholecystotomy.  If  this  condition  is  found,  or  if  gall  stones  are  discov- 
ered in  the  gall  bladder  or  the  cystic  duct,  but  none  in  the  hepatic  or  common 
ducts,  this  operation  is  plainly  indicated. 

The  examination  may  have  revealed  more  or  less  extensive  recent  or 
old  adhesions  between  the  gall  bladder  and  the  surrounding  organs. 

These  adhesions  may  include  the  liver,  the  omentum,  the  transverse 
colon,  the  duodenum,  or  the  stomach  and  in  some  instances  even  the  right 
kidney,  or  they  may  include  any  two  or  more  of  these  organs. 

If  they  are  recent,  or  if  they  distort  one  or  more  of  these  organs,  it  is 


PLATE  XCVII. 

A.  B.  Trocar  for  aspirating  the  fluid  from  the  gall  bladder.  C.  Double  scoop  for 
removing  gall  stones.  D.  Forceps  for  removing  gall  stones.  E.  Rubber  tube  used  for 
the  hepatic  or  the  common  duct. 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  615 

well  to  loosen  or  ligate  and  cut  these  adhesions.  If  they  have  existed  for 
a  long  period  of  time  without  apparently  doing  any  harm,  it  is  better  to 
leave  them  undisturbed.  It  must,  however,  be  borne  in  mind  that  undoubt- 
edly the  adhesions  of  the  gall  bladder  frequently  draw  this  down  and  cause 
it  to  become  sacculated  so  that  it  will  contain  residual  bile,  which  in  turn 
favors  infection  of  this  fluid,  and  thus  the  formation  of  gall  stones.  It  is 
consequently  important  to  remove  any  adhesions  which  seem  to  show  a 
tendency  to  cause  sacculation  of  the  gall  bladder. 

This  having  been  accomplished,  soft  gauze  pads  moistened  with  warm 
normal  salt  solution  are  placed  about  the  gall  bladder  after  the  latter  has 
been  grasped  at  its  most  prominent  point  with  one  or  two  pairs  of  forceps. 

This  act  of  packing  away  the  remaining  portion  of  the  peritoneal  cavity 
should  be  done  with  the  greatest  care,  to  prevent  soiling  during  the  fol- 
lowing steps  of  the  operation. 

A  trocar  is  then  plunged  into  the  gall  bladder  to  drain  away  the  bile, 
pus  or  mucus,  as  the  case  may  be,  contained  in  the  cavity.  The  trocar 
devised  by  Dr.  E.  H.  Ochsner,  is  undoubtedly  most  convenient  because 
with  it  the  gall  bladder  can  be  emptied  perfectly  without  the  slightest  dam- 
age of  soiling  any  of  the  surrounding  tissues. 

Should  the  gall  bladder  be  contracted  because  of  the  long-continued 
destructive  inflammation,  which  distinguishes  old  gall  stone  cases  from 
obstruction  due  to  malignant  growths  according  to  the  law  of  Courvoiser, 
it  might  not  be  necessary  to  make  use  of  the  trocar,  because  there  will  be 
no  bile  in  what  is  left  of  the  gall  bladder.  In  these  cases  the  most  promi- 
nent portion  of  the  gall  bladder  is  grasped  by  the  forceps  and  an  incision 
made  through  the  highest  part,  which  is  also  the  next  step  after  the  fluid 
has  been  aspirated  in  the  other  class  of  cases. 

If  there  is  still  a  little  fluid  present,  this  is  absorbed  by  lightly  tampon- 
ing the  cavity  of  the  gall  bladder  with  a  narrow  strip  of  aseptic  gauze  and 
withdrawing  it.  This  can  be  repeated  a  number  of  times.  A  blunt  gall 
stone  scoop  is  now  introduced  and  gently  withdrawn,  bringing  out  as  many 
of  the  stones  as  can  be  reached  in  this  manner.  Then,  while  the  assistant 
holds  up  the  gall  bladder  with  hemostatic  forceps  attached  to  the  edge  of 
the  wound,  the  surgeon's  hand  is  again  introduced  into  the  abdominal  cavity, 
and  the  gall  bladder  and  all  its  ducts  are  once  more  carefully  palpated. 

If  stones  are  still  present,  these  can  be  removed  with  the  scoop,  guided 
by  the  hand  in  the  abdominal  cavity.  If  there  are  stones  in  the  cystic  duct, 
these  can  frequently  be  forced  back  into  the  gall  bladder  by  a  gentle  "milk- 
ing" motion  between  the  forefinger  and  thumb.  Occasionally  this  can  be 
aided  by  the  use  of  a  small  curette  guided  by  the  other  hand. 

In  a  few  instances  it  has  been  possible  to  transfer  to  the  gall  bladder 
not  only  stones  in  the  cystic  duct  but  even  those  in  the  common  and  hepatic 
duct.  Great  caution  must,  however,  be  practised,  because  less  injury  is 
done  to  the  patient  by  making  an  incision  into  these  ducts  than  by  severe 
manipulation  in  the  attempt  at  removing  stones,  especially  if  these  are  im- 
movable as  the  result  of  impaction. 

So  far,  the  steps  of  the  operation  are  agreed  upon  practically  by  every 
one  who  has  had  a  large  experience  in  the  treatment  of  these  cases.  But 
from  this  point  on,  authorities  of  equal  ability  vary  in  details  of  their 
technique. 

Varying  Methods. 

We  have  used,  at  various  times,  most  of  the  methods  that  have  been 


6l6  SURGERY    Of    THE    GALL    BLADDER    AND    LIVER 

recommended,  thinking  one  might  be  indicated  under  certain  conditions, 
while  another  might  be  more  suitable  for  a  slightly  different  case,  but  we 
are  convinced  that  the  special  benefits  from  these  various  operations  are 
entirely  imaginary,  and  that  this  is  simply  a  remnant  of  the  pedantry  which 
has  been  so  uniformly  a  part  of  our  professional  work  for  centuries. 

A  Proven  Simple  Technique. 

In  more  than  one  thousand  successive  cases  we  have  employed  the 
following  simple  technique,  after  being  satisfied  that  all  the  stones  had  been 
removed. 

1.  The  gall  bladder  is  carefully,  but  gently  and  loosely,  tamponed  with 
a  long  strip  of  dry  gauze.     This  serves  to  prevent  hemorrhage  from  the 
mucous  lining  of  the  gall  bladder  which  is  frequently  severely  congested 
and  often  covered  with  bleeding  granulations. 

2.  The  transversalis  fascia  and  the  peritoneum  of  the  upper  angle  of 
the  wound  is  then  sutured  to  the  edge  of  the  gall  bladder,  one  to  two  cm. 
back  from  the  edge  of  the  opening.     Plate  XCVIII  shows  the  gall  bladder 
with  the  forceps  upon  its  edge  and  drawn  out  through  the  wound,  and  a  cat- 
gut stitch  being  placed  which  attaches  the  gall  bladder  to  the  peritoneum. 
The  stitch  in  the  gall  bladder  passes  down  to,  but  not  through,  the  mucous 
lining  of  the  gall  bladder. 

If  the  gall  bladder  is  small  and  shrunken  the  peritoneum  and  trans- 
versalis are  brought  dow7n  to  it  at  one  or  two  points  and  a  piece  of  gauze 
is  carried  down  to  the  gall  bladder,  and  between  the  gauze  and  the  sur- 
rounding tissue  a  piece  of  rubber  tissue  is  placed.  Attaching  the  gall 
bladder  in  this  manner  facilitates  drainage,  and  prevents  the  gall  bladder, 
later  on,  from  becoming  sacculated. 

3.  The  abdominal  wall  is  now  closed  as  illustrated  in  Plate  LX.     Two 
of  the  fine  silk-worm  gut  stitches  are  passed  through  all  the  tissues  down 
to,  but  not  through,  the  transversalis  fascia ;  these  are  left  untied  until  the 
following  rows  of  catgut  sutures  have  been  applied  in  order  to  prevent  the 
formation   of   a  ventral  hernia,   by  carefully  approximating  the   following 
layers ;  a,  peritoneum  and  transversalis  fascia ;  b,  rectus  abdominis  muscle, 
aponeurosis   of   the   external   and   the   outer   layer   of  the   internal   oblique 
muscle  passing  in  front  of  the  rectus  abdominus  muscle  at  this  point;  d, 
the  skin. 

These  layers  are  all  approximated  by  suturing  with  unchromicized  cat- 
gut, except  the  skin,  for  which  horse-hair  is  used.  Now  by  tying  the  silk- 
worm gut  sutures  the  closure  of  the  wound  is  completed. 

4.  Some  rubber  tissue  is  now  stuffed  down  to  the  gall  bladder,  be- 
tween the  edges  of  the  abdominal  wall  and  the  gauze  tampon,  to  facilitate 
the  removal,  about  the  fifth  day,  when  a  rubber  drainage  tube  is  inserted 
in  the  gall  bladder  in  its  place. 

Other  Methods. 

The  other  methods  which  seem  equally  satisfactory  consist  in  sub- 
stituting for  the  gauze  tampon  in  the  gall  bladder,  a  simple  rubber  tube,  or 
a  split  rubber  tube  filled  with  a  strip  of  gauze  or  a  cigarette  drain.  Any 
one  of  these  may  be  fastened  in  the  gall  bladder  by  placing  a  purse-string 
suture  around  the  opening,  inverting  the  edges,  and  then  drawing  the  purse- 
string  just  sufficiently  tight  to  prevent  leakage. 

Still  another  method  consists  in  applying  one  of  these  various  forms 
of  drainage,  and  then  simply  permitting  this  to  project  from  the  upper 


PLATE  XCVIII. 
CHOLECYSTOTOMY. 

The  wound  is  held  open  by  means  of  sharp  retractors.  The  gall  bladder  is  drawn 
out  of  the  abdominal  wound  by  means  of  haemostatic  forceps  ;  one  suture  is  in  place 
attaching  the  gall  bladder  to  the  peritoneum  and  transversalis  fascia,  and  a  second 
suture  is  being  applied.  The  umbilicus  should  be  opposite  the  lower  end  of  the 
incision,  instead  of  being  opposite  its  center. 

This  incision  should  be  three  inches  nearer  the  costal  arch.  It  is  well  to  insert 
the  suture  on  the  side  of  the  gall  bladder  transverse1}-  in  order  to  grasp  and  compress 
the  branches  of  the  cystic  artery  more  perfectly.  Omitting  this  precaution  may  occa- 
sionallv  re-uH  in  severe  hrrmcrrhaee. 


PLATE  XCIX. 

RETEXTIOX    TUBE.   AFTER  THE   PLAN  OF   JACOB'S   RETENTION*   CATHETER. 

a  shows  the  bulh-Hke  end  in  the  position  it  takes  when  in  place,  b  shows 
the  end  stretched  over  a  probe  c  in  order  to  reduce  its  size  during  its  intro- 
duction. To  be  used  in  draining  cavities  like  the  urinary  bladder,  gall  bladder, 
hydronephric  kidney,  etc.  This  tube  is  also  used  as  a  permanent  feeding  tube  in 
gastrostomy. 


PLATE  C. 

REMOVAL  OF  STOXE  FROM  COMMON  DUCT  AND  DRAINAGE  OF  COMMON  DUCT. 

Sutures  of  fine  catgut  are  applied  to  each  side  of  the  proposed  incision. 
These  are  utilized  later  to  hold  in  place  a  rubber  drainage  tube  which  is  in- 
serted in  the  incision  in  the  common  duct,  and  also  for  fastening  a  piece  of  gauze 
which  is  packed  around  the  tube  to  further  protect  the  general  peritoneal  cavity 
against  contamination. 

(Taken  from  Dr.  W.  J.  Mayo's  original  drawings.) 


PLATE  CI. 

EXCISION  OF  THE  GALL  BLADDER. 

Two  pairs  of  forceps  arc  in  place,  one  grasping  the  neck  of  the  gall  bladder 
at  its  entrance  into  the  cystic  duct,  the  other  grasping  the  cystic  duct  just  below 
this  point.  Koth  forceps  also  grasp  the  cystic  artery.  A  dotted  line  indicates 
the  position  of  a  stone  in  the  neck  of  the  gall  bladder  wedged  in  and  obstructing 
the  latter.  The  ga'l  bladder  is  to  be  removed  from  below  upward,  the  forceps 
applied  to  the  neck  of  the  gall  bladder,  including  the  cystic  artery,  making  the 
operation  almo-t  bloodless. 

(Taken  from  Dr.  \Y.  J.  Mayo's  original   dra-.v:::;^-; 


PLATE  CII. 

EXCISION  OF  THE  GALL  BLADDER  BEGINNING  FROM  BELOW. 
A  ligature  has  been  placed  around  the  cystic  duct.  The  neck  of  the  gall 
bladder  just  above  the  cystic  duct  is  grasped  by  forceps  to  prevent  leakage.  A 
dotted  line  indicates  the  position  of  a  stone  wedged  into  the  neck  of  the  gall 
bladder  and  causing  complete  obstruction.  The  cystic  duct  and  the  common  duct 
are  also  shown.  Sutures  are  in  place  to  close  the  space  formed  by  the  loosening 
of  the  gall  bladder. 

(Taken  from  Dr.  W.  J.  Mayo's  original  drawings.) 


H 
W 

o 


H 
M 

n 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  63! 

angle  of  the  abdominal  wound  without  suturing  the  gall  bladder  to  the 
parietal  peritoneum.  Personally,  we  have  never  been  favorably  impressed 
by  this  course. 

In  case  it  seems  wise  to  continue  the  drainage  of  the  gall  bladder  for 
a  considerable  period,  the  patient  can  be  made  more  comfortable  by  insert- 
ing a  Jacob's  retention  catheter  of  proper  size  into  the  gall  bladder,  placing 
a  glass  tube  in  the  distal  end  of  this  catheter  and  tying  a  soft  rubber  bag 
to  this  in  order  to  collect  the  bile.  (Plate  XCIX.)  Whenever  it  seems  the 
proper  time  to  interrupt  this  drainage,  the  opening  will  close  spontaneously 
upon  withdrawing  the  catheter. 

i.  \  • '  CHOLECYSTECTOMY. 

This  operation  seems  indicated  in  cases  in  which  there  is  a  permanent 
obstruction  of  the  cystic  duct,  which  is  usually  due  to  a  cicatricial  contrac- 
tion of  an  ulcer,  most  commonly  caused  by  the  impaction  of  a  stone. 

It  may  also  be  due  to  the  formation  of  a  valve  in  the  neck  of  the  gall 
bladder  at  its  entrance  into  the  cystic  duct.  Occasionally  such  a  valve  will 
permit  the  free  flow  of  bile  into  the  gall  bladder,  but  will  not  in  the  oppo- 
site direction.  The  gall  bladder  should  also  be  removed  in  cases  in  which 
its  walls  are  so  thin  that  it  will  not  be  able  to  act  as  a  contractile  organ. 

Cholecystectomy  should  be  performed  in  early  cases  of  primary  car- 
cinoma of  the  gall  bladder.  In  some  cases  in  which  the  gall  bladder  has 
been  badly  diseased  for  some  time,  the  disease  being  limited  to  the  organ 
alone,  and  circumstances  permit  of  easy  removal,  cholecystectomy  will  be 
the  operation  of  choice. 

The  removal  of  the  gall  bladder  is  usually  not  a  difficult  matter  if  it  is 
approached  from  the  right  direction.  The  following  simple  steps  should  be 
followed. 

1.  The  same  incision  as  in  cholecystotomy  should  be  made.     Occa- 
sionally if  there  are  many  adhesions,  so  that  it  is  difficult  to  reach  the  lower 
end  of  the  gall  bladder,  the  incision  may  be  lengthened,  according  to  the 
plan  advised  by  Bevan,  by  extending  the  upper  end  of  the  incision  inward 
and  the  lower  end  outward ;  or  it  may  be  extended  according  to  Mayo  Rob- 
son,  between  the  edge  of  the  costal  cartilages  and  the  lower  end  of  the 
sternum,  in  order  that  the  liver  with  the  gall  bladder  may  be  inverted  up- 
ward. 

2.  Two  pair  of  hemostatic  forceps  are  then  applied,  one  directly  to 
the  cystic  duct,  grasping  at  the  same  time  the  cystic  artery  which  supplies 
the  gall  bladder ;  the  second  pair  is  applied  to  the  neck  of  the  gall  bladder 
at  a  distance  of  one  cm.   from  the  other.     Plate  CI   shows  the  two  pair 
of  forceps  in  place.    The  gall  bladder  is  now  cut  loose  just  beyond  the  second 
forceps  and  between  this  and  the  first  pair,  as  shown  in  Plate  CII. 

3.  An   incision   is   now   made   along  the   sides   of   the   gall   bladder, 
through  its  peritoneal  covering,  about  one  cm.  from  its  attachment  to  the 
liver,  and  then  the  organ  can  be  enucleated  without  difficulty. 

If  there  is  any  considerable  amount  of  hemorrhage  from  the  surface,  a 
hot  tampon  of  gauze  against  the  surface  for  a  few  minutes  will  control  the 
oozing  at  once,  and  then  the  raw  surface  can  be  closed  by  suturing  the  two 
peritoneal  folds  with  catgut  as  shown  in  Plate  CII. 

Plate  CIII  (a),  shows  the  cutting  of  the  peritoneal  fold  between  the 
gall  bladder  and  the  liver.  Plate  CIII  (b)  where  the  gall  bladder  and  the 


632  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

cystic  duct  have  been  removed.  Plate  CIV  (a)  where  the  two  edges  of  the 
peritoneum  have  been  sutured  covering  over  the  raw  surface  made  by 
excising  the  gall  bladder.  Plate  CIV  (b)  shows  rubber  drain  placed  in 
hepatic  duct  which  is  pulled  downwards  for  sake  of  illustration. 

4.  Disposition  of  the  stump.  If  drainage  is  not  desired,  a  ligature  can 
be  placed  about  the  stump  of  the  cystic  duct,  including  the  cystic  artery,  as 
shown  in  Plate  CII. 

If  it  is  doubtful,  the  artery  forceps  may  be  left  in  place,  and  may  be 
surrounded  by  gauze  and  rubber  protective,  and  permitted  to  pass  out  of 
the  upper  angle  of  the  wound.  This  may  be  loosened  after  thirty-six  hours, 
or  sooner,  if  it  should  become  apparent  that  drainage  is  desired. 

It  is  well  in  these  cases  to  insert  a  drainage  tube  to  a  point  just  below 
the  stump  for  the  purpose  of  providing  for  an  emergency.  It  is  imma- 
terial what  form  of  drainage  tube  is  chosen.  In  case  drainage  of  the  cystic 
duct  is  desired,  the  cystic  artery  is  caught  separately  at  the  end  of  the 
stump  and  ligated  and  a  small  rubber  drainage  tube  is  introduced  directly 
into  the  common  duct  through  the  cystic  duct. 

Plate  XCVII  figure  (e)  shows  a  drainage  tube  which  is  most  useful  in 
these  cases.  A  small  rubber  drainage  tube  is  drawn  through  a  larger  tube, 
the  perforated  end  is  introduced  into  the  cystic  duct,  and  it  is  held  in  place 
by  one  or  more  catgut  sutures,  which  pass  through  the  outer  tube  but  do  not 
touch  the  inner  tube.  By  the  time  the  catgut  is  absorbed,  it  is  time  to  with- 
draw the  drainage  tube. 

The  abdominal  wound  is  closed  as  in  the  previous  operation,  and  the 
tissues  are  prevented  from  adhering  to  the  gauze  by  the  interposition  of  rub- 
ber tissue. 

CHOLEDOCHOTOMY. 

In  operation  upon  the  common  duct  a  sand  bag  is  always  placed  under 
the  back  opposite  the  liver,  as  advised  by  Mayo  Robson.  The  usual  straight 
incision  is  made  through  the  right  rectus  muscle.  If  it  is  found  necessary 
to  open  the  common  duct  and  more  room  is  desired,  the  incision  is  carried 
upward  and  inwards  between  the  right  costal  margin  and  the  ensiform  car- 
tilage. Now  by  lifting  the  lower  edge  of  the  liver  out  of  the  wound,  it  will 
be  found  that  the  gall  bladder  and  the  cystic  and  common  ducts  will 
be  brought  into  plain  view.  The  liver  is  held  in  this  position  by  an 
assistant  who  grasps  the  lower  edge  of  the  liver  with  his  fingers  covered 
with  a  piece  of  dry  gauze.  When  the  liver  is  held  in  this  position  it  will  be 
found  that  the  cystic  and  common  ducts  make  an  almost  straight  passage 
from  the  neck  of  the  gall  bladder  to  the  entrance  into  the  duodenum. 

If  there  are  adhesions  about  the  ducts,  these  are  separated  and  a  spoon 
is  placed  in  the  kidney  pouch  and  the  entire  field  of  operation  protected  by 
sterile  pads. 

The  stone  is  located  and  grasped  between  the  thumb  and  finger  of  the 
left  hand.  While  the  stone  is  held  in  this  position,  two  catgut  sutures 
are  placed  into  the  side  of  the  common  duct  directly  over  the  stone.  These 
sutures  are  left  long.  A  little  tension  is  made  upon  the  sutures,  then  the 
duct  is  opened  by  making  a  longitudinal  incision  between  the  two  sutures 
directly  over  the  stone. 

Plate  C  illustrates  a  stone  in  the  common  duct,  and  two  catgut  sutures 
applied  to  each  side  of  the  proposed  incision  and  the  incision  made  directly 
over  the  stone. 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  635 

After  all  obvious  stones  have  been  removed,  the  finger  should  be  passed 
into  the  duct  to  detect  any  stones  that  might  be  above  or  below  the  incision. 

Any  sand  or  thick  bile  is  removed  by  packing  strips  of  gauze  into  the 
duct  in  the  manner  described  in  sponging  out  the  gall  bladder.  When  the 
duct  is  clear,  the  incision  in  it  may  be  closed  by  suture  or  may  be  drained. 
If  there  is  not  much  evidence  of  infection  of  the  common  duct,  and  the  gall 
bladder  looks  healthy  and  the  cystic  duct  is  patent,  the  wound  in  the  common 
duct  can  be  closed  with  safety,  leaving  drainage  of  the  bile  through  the 
gall  bladder  only.  The  incision  in  the  duct  is  closed  by  first  approximating 
the  edges  with  a  fine  continuous  catgut  stitch,  and  over  this  a  few  Lembert 
stitches  of  silk.  A  cigarette  drain  is  placed  down  to  the  common  duct  and 
brought  up  out  of  the  incision  by  the  side  of  the  gall  bladder  drain. 

The  majority  of  the  cases  require  drainage  of  the  common  duct, 
especially  in  those  where  the  head  of  the  pancreas  is  enlarged  from  chronic 
pancreatitis. 

A  double  drainage  tube  as  shown  in  Plate  XCVII  figure  (e),  is  inserted 
into  the  common  duct  and  carried  upwards  towards  the  hepatic  duct.  The 
two  catgut  sutures  which  were  placed  in  the  sides  of  the  duct  are  now 
utilized  to  fasten  the  drainage  tube  in  place,  which  is  done  by  passing  the 
sutures  through  the  outer  rubber  tube  and  tying.  These  sutures  are  still 
left  long. 

Now  a  piece  of  iodoform  gauze  is  packed  around  the  tube  and  brought 
up  out  of  the  wound  by  the  side  of  the  drainage  tube  to  further  protect  the 
peritoneal  cavity.  These  same  sutures  are  now  passed  through  the  gauze 
and  tied  so  that  there  can  be  no  displacement  of  the  gauze  should  the  patient 
vomit  after  the  operation. 

The  operation  is  completed  by  closing  the  wound  in  the  usual  manner. 

CHOLECYSTENTEROSTOMY. 

This  operation  is  indicated  in  cases  in  which  there  is  a  permanent 
obstruction  between  the  entrance  of  the  hepatic  duct  into  the  common  duct 
and  the  opening  of  the  latter  into  the  duodenum,  also  in  cases  of  chronic 
interstitial  pancreatitis. 

The  entire  alimentary  canal  should  be  thoroughly  emptied  before 
the  operation  is  undertaken,  by  the  administration  of  two  large  doses  of 
castor  oil,  twelve  to  twenty-four  hours  apart,  then  a  careful  anastomosis 
from  one-half  to  one  inch  in  length  should  be  made  by  any  one  of  the 
various  methods  employed  in  making  intestinal  anastomosis  with  needle 
and  thread. 

If  a  mechanical  device  is  employed,  the  small  Murphy  button  should 
be  chosen,  but  the  suture  seems  to  be  a  superior  method. 

After  Treatment. 

When  the  operation  is  completed  a  dry  sterile  gauze  dressing  is  applied 
and  held  in  place  by  an  abdominal  bandage  applied  tightly,  so  that  if  vomit- 
ing should  occur,  the  wound  will  receive  some  support  from  the  bandage. 

No  water  is  allowed  by  mouth  until  the  other  sickness  and  the  nausea  are 
over.  If  the  thirst  is  great,  the  mouth  may  be  flushed  frequently  with  water 
and  an  enema  of  a  pint  of  salt  solution  may  be  given. 

If  the  pain  is  severe,  morphia  in  doses  of  %  to  %  of  a  grain  may  be 
given  hypodermically. 

Four  to  eight  ounces  of  normal  salt  solution  are  given  as  an  enema 


636  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

every  four  hours  for  the  first  twenty-four  hours.  Then  nourishing  enemata 
in  the  form  of  liquid  peptonoids,  one  ounce,  with  normal  salt  solution  four 
ounces,  are  administered  every  four  hours,  for  two  or  three  days. 

As  soon  as  the  sickness  from  the  anaesthetic  is  over,  small  quantities  of 
water  may  be  given  by  mouth,  and  on  the  third  or  fourth  day  beef  tea  or 
broth  may  be  allowed  increasing  the  diet  slowly  from  this  time  on. 

The  wound  is  dressed  daily  with  dry  sterile  gauze,  and  on  the  fourth 
day  the  gauze  is  removed  from  the  gall  bladder  and  a  rubber  tube  substi- 
tuted, which  in  ordinary  cases  is  removed  at  the  end  of  a  week  or  ten  days, 
and  the  wound  allowed  to  close. 

In  cases  accompanied  with  pancreatitis  or  a  marked  cholangitis,  the 
drainage  is  continued  for  a  period  of  from  two  or  four  weeks. 

The  stitches  are  removed  on  the  twelfth  day  and  the  patient  allowed 
to  get  up  at  the  end  of  fourteen  to  eigtheen  days. 

Constriction  of  the  Duodenum  Below  the  Entrance  of  the   Common  Duct. 

Several  years  ago  our  attention  was  first  directed  to  an  interesting  con- 
dition which  is  frequently  present  in  patients  who  come  under  observation 
during  gall-bladder  and  stomach  operations. 

In  many  of  these  cases  the  duodenum  is  distended  with  gas  to  a  point 
just  below  the  entrance  of  the  common  duct,  while  below  this  it  is  con- 
tracted, and  upon  raising  the  transverse  colon  and  finding  the  origin  of  the 
jejunum,  this  portion  of  the  intestine  will  also  be  found  contracted.  In 
looking  over  authorities  upon  the  subject  of  anatomy,  we  found  that  they 
all  state  that  the  third  portion  of  the  duodenum  is  the  narrowest  part  of 
this  intestine  if  they  make  any  statement  upon  the  subject.  They  also  state 
that  the  first  portion  of  the  duodenum  is  usually  found  stained  with  bile 
after  death.  Several  further  clinical  observations  pointed  in  the  same  di- 
rection. It  was  found  that  the  dilatation  of  the  upper  portion  of  the  duode- 
num was  most  commonly  present  in  patients  suffering  from  chronic  chole- 
cystitis with  sand  or  gallstones  in  the  gall-bladder.  In  these  cases  there 
was  frequently  a  more  or  less  marked  enlargement  of  the  pancreas. 

In  having  the  vomitus  examined  systematically  for  a  considerable 
period  of  time  in  patients  who  had  been  subjected  to  general  anesthesia  for 
operation,  it  was  found  that  it  invariably  contained  bile,  showing  that  there 
must  be  some  reason  why  this  fluid  should  be  forced  upward  past  the  pyloric 
sphincter  rather  than  downward  through  the  small  intestine. 

Again,  it  was  found  that  in  patients  suffering  from  acute  gall-stone 
colic,  the  spasmodic  pain  would  subside  invariably  within  a  few  hours  upon 
making  careful  gastric  lavage  and  prohibiting  the  introduction  of  any  kind 
of  food  into  the  stomach,  although  without  this  aid  large  doses  of  morphine, 
given  hypodermically,  had  given  at  best  only  temporary  relief. 

This  seemed  to  indicate  that  there  must  be  some  point  near  the  entrance 
of  the  common  duct  into  the  duodenum  which  regulates  the  passage  of  food 
through  tli is  intestine. 

These  clinical  observations  induced  us  to  make  a  careful  anatomical 
study  of  this  portion  of  the  small  intestine,  both  in  the  living  patient  and  in 
the  cadaver. 

An  assistant.  Dr.  K.  \Y.  Thuerer,  made  a  careful  examination  of  the 
duodenum  in  thirty-nine  cadavers,  which  revealed  in  every  specimen  an  ana- 
tomical condition  of  the  duodenum  consisting  in  a  marked  thickening  of  the 
circular  muscle  fibres  of  this  portion  of  the  alimentary  canal  at  a  point  be- 


Pylorus;  E.C.,  common  duel;  E>.ofW.,  duct  of  Wirsuncf  ,   S,  a 
doulle 


lorus;    JD.C.,  camtnoft  duct ,      E>.of~J4/~.,c}u.c"tofWt>rsuncf; 
>,t  o/    (/Deafest    cLevelofrntetit  of  <;  ircu/ur   -muscle  fib're. 


PLATE  CVI. 

Shows  drawings  of  two  specimens  removed  from  the  cadaver,  showing  the  loca- 
tion of  the  circular  muscle  fibers  of  the  duodenum. 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  639 

low  the  entrance  of  the  common  duct.  Plate  CVI  is  a  drawing  of  two 
typical  specimens  removed. 

A  considerable  variation  was  found  in  the  exact  position  of  these 
muscle  fibres.  In  some  instances  they  were  arranged  in  a  narrow  circular 
band  forming  a  distinct  sphincter;  in  others  the  thickening  was  diffused, 
making  a  broad,  circular  band ;  and  in  a  few  instances  the  thickening  was  in 
two  different  bands,  with  an  intervening  portion  in  which  the  circular  muscle 
fibres  were  of  the  same  thickness  as  the  remaining  portion  of  the  duodenum. 

There  was  a  further  difference  in  the  location  of  this  duodenal  sphinc- 
ter ;  in  most  specimens  it  was  located  from  3  to  10  cm.  below  the  point  of 
entrance  of  the  common  duct,  while  in  a  few  instances  a  portion  of  the 
sphincter  included  a  point  of  entrance  of  the  common  duct,  the  remaining 
portion,  however,  being  always  located  below  this  point. 

These  conditions  seem  to  explain  a  number  of  physiological  facts ;  that 
vomiting  when  the  stomach  is  relatively  empty  always  expels  a  certain 
amount  of  bile ;  and  that  in  many  cases  in  which  there  is  a  dilatation  of  the 
stomach  without  constriction  of  the  pylorus,  with  an  ulcer  in  the  pyloric 
end,  the  ulcer  frequently  extends  into  the  duodenum.  It  may  also  explain 
some  of  the  stomach  symptoms  which  are  so  constantly  observed  in  con- 
nection with  gallstone  disease.  It  will  also  explain  a  condition  not  infre- 
quently encountered  in  operating  for  the  relief  of  gallstones  and  ulcer  of 
the  stomach,  that  is,  the  presence  of  a  greatly  distended  duodenum,  with  a 
completely  contracted  first  portion  of  the  jejunum. 

It  also  explains  the  presence  of  the  bile-staining  of  the  portion  of  the 
duodenum  above  the  common  duct  in  the  cadaver,  while  the  portion  below 
this  point  is  usually  free.  This  has  been  noted  by  many  observers. 

It  has  seemed  as  though  this  arrangement  of  circular  muscle  fibres 
served  the  purpose  of  a  sphincter  to  facilitate  the  process  of  mixing  the 
bile  and  the  pancreatic  juice  in  the  duodenum;  which  has  been  so  perfect- 
ly described  by  Cannon. 

The  presence  of  a  gastric  ulcer  in  a  considerable  proportion  of  patients 
that  have  suffered  from  chronic  appendicitis  may  have  some  relation  to  this 
condition  in  the  following  manner :  There  is  undoubtedly  an  obstruction  of 
the  ileocecal  valve,  due  to  the  physiological  contraction  of  this  sphincter 
during  an  acute  exacerbation  of  appendicitis,  for  the  purpose  of  establishing 
a  condition  of  rest  in  this  vicinity.  This  is  followed  by  nausea  and  vomit- 
ing, and  it  seems  reasonable  to  suppose  that  the  ileocecal  valve  initiates  re- 
turn peristalsis  and  that  this  in  turn  excites  a  contraction  of  the  duodenal 
sphincter  ami  the  pyloric  sphincter,  and  that  in  this  way  a  normal  passage 
of  food  from  the  stomach  into  the  intestines  is  interfered  with,  causing  an 
accumulation  of  residual  food  in  the  stomach,  and  that  the  irritation  caused 
in  this  manner  may  be  an  etiological  factor  in  the  production  of  gastric  ulcer. 
It  may  also  explain  the  presence  of  bile  in  the  vomitus  of  patients  suffering 
from  intestinal  obstruction. 

ABSCESS   OF    THE    LIVER. 

Cases  of  suppuration  in  the  liver,  other  than  those  found  in  tropical 
countries,  are  usually  due  to  metastases  of  pyemia. 

Dysentery  is  far  the  most  frequent  cause  of  abscesses  of  the  liver. 
They  are  very  common  in  the  tropical  countries  where  the  various  inflam- 
matory conditions  of  the  bowels  produce  a  thrombo-phlebitis  of  the  mesen- 


640  SURGERY    01-     THE    GALL    BLADDER    AND    LIVER 

teric  vein ;  the  clots  decompose,  become  dislodged  and  carry  the  infection 
through  the  branches  of  the  portal  vein,  resulting  in  abscesses  of  the  liver. 

The  amoebae  dysenteriae  have  frequently  been  found  in  the  pus  from 
these  abscesses. 

Liver  abscesses,  other  than  those  occurring  during  the  course  of  dysen- 
tery, may  be  due  to  gall  stones,  typhoid  fever,  intestinal  ulcers,  inflammation 
in  region  of  the  portal  vein,  trauma,  syphilis  and  also  as  one  of  the  complica- 
tions following  a  suppurative  appendicitis.  It  also  has  resulted  from  ac- 
tinomycosis  of  the  liver. 

Symptoms. 

The  most  constant  symptoms  are,  first,  a  history  in  which  dysentery 
and  chill  a'ppear ;  second,  general  malaise  pronounced ;  third,  pain  and  ten- 
derness over  liver;  fourth,  enlargement  of  the  liver;  fifth,  hectic  sweats, 
and  rigors ;  sixth,  right-side  posture ;  seventh,  erratic  temperature  running 
from  96.5  to  103.5°  F. ;  eighth,  progressive  emaciation;  ninth,  gastric  dis- 
turbances. 

Pain  in  region  of  liver  is  usually  an  early  and  prominent  symptom. 
The  pain  often  follows  the  course  of  the  phrenic  and  fourth  cervical  nerves 
and  radiates  toward  the  right  shoulder.  It  is  usually  constant  from  the  on- 
set. By  carefully  noting  the  exact  limits  of  the  pain  and  tenderness  the 
abscess  may  often  be  located.  Pain  is  always  increased  by  digital  pressure. 

Enlargement  of  the  liver  is  perhaps  the  most  invariable  objective  symp- 
tom, and  usually  causes  a  bulging  of  the  right  hypochondrium.  The  en- 
largement may  take  place  in  any  direction.  The  expansion  takes  the  course 
of  the  least  resistance  and  may  be  the  means  of  determining  the  seat  of  the 
abscess. 

Prognosis. 

The  prognosis  is  unfavorable  especially  in  cases  of  multiple  abscesses. 
The  patient  may  succumb  to  the  primary  infectious  disease,  or  to  pyemia  or 
sepsis,  or  the  abscesses  may  rupture  into  the  peritoneal  cavity  causing  a 
septic  peritonitis,  or  may  rupture  into  the  pleural  cavity  resulting  in  septic 
pneumonia. 

Treatment. 

The  treatment  is  operative.  The  liver  must  be  reached  by  crossing 
either  the  pleura  or  the  peritoneum,  the  route  chosen  according  to  the 
location  of  the  abscess.  If  there  is  reason  to  believe  that  the  abscess  is 
not  pointing  toward  the  pleura,  or  has  not  ruptured  into  it,  the  liver  is 
reached  through  the  peritoneal  cavity  by  making  an  incision  high  up 
through  the  right  rectus  abclominus  muscle.  The  abdominal  cavity  is  care- 
fully walled  off  by  gauze  pads.  If  the  abscess  is  not  readily  discovered,  the 
liver  may  be  explored  by  means  of  an  aspirating  needle.  The  abscess  is 
then  incised  freely  and  the  cavity  packed  with  iodoform  gauze.  Other 
pieces  of  iodoform  gauze  are  so  arranged  as  to  protect  the  general  peri- 
toneal cavity  and  brought  out  through  the  incision. 

In  cases  in  which  the  abscess  is  evident  on  exposure  of  the  liver, 
the  operation  may  be  clone  in  two  stages.  The  surface  of  the  liver  at  the 
point  of  suppuration  is  exposed,  and  the  wound  packed  with  iodoform 
gauze  and  left  three  or  four  days  until  adhesions  have  formed,  and  then  the 
operation  is  completed. 

In  passing  through  the  pleura,  it  is  necessary  to  resect  one  or  more 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  641 

ribs.  When  the  parietal  pleura  is  incised  its  edges  are  caught  by  hemo- 
static  forceps.  The  diaphragmatic  pleura  is  now  incised  and  its  margins 
sewed  to  those  of  the  parietal  pleura  so  as  to  close  the  pleural  cavity.  The 
operation  is  completed  by  incising  through  the  diaphragm  and  draining  the 
abscess  freely. 

In  cases  in  which  there  is  redness  and  edema  of  the  skin,  making  it 
evident  that  adhesions  exist,  the  abscesses  may  be  incised  directly. 

HYDATIDS    OF  THE   LIVER. 

This  disease  is  caused  by  a  parasite  known  as  the  tenia  echinococcus 
whose  normal  habitat  is  in  the  intestinal  canal  of  dogs,  jackals  and  wolves. 

The  disease  is  most  prevalent  in  Australia  and  Iceland  where  the 
natives  are  not  cleanly  and  live  in  close  association  with  dogs. 

The  tenia  are  taken  into  the  alimentary  canal  with  the  food,  or  more 
commonly  with  drinking  water.  According  to  Fowler  their  albuminous 
envelope  is  partly  digested  in  the  stomach  and  thus  set  free  they  burrow  into 
the  tissues  and  most  frequently  enter  a  radicle  of  the  portal  vein  and  are 
thus  carried  to  the  liver. 

There  is  some  question  as  to  what  becomes  of  the  liver  tissue  where 
these  large  cysts  develop  in  the  organ.  Some  authors  believe  that  an 
atrophy  takes  place,  while  others  think  that  a  hyperthrophy  occurs. 

When  the  cyst  is  fully  developed  there  is  a  sac  filled  with  fluid  in  which 
float  smaller  cysts  known  as  daughter  cysts,  and  sometimes  there  are  tertiary 
cysts  inside  of  these. 

The  booklets  of  the  parasite  are  usually  found  in  the  cyst  wall. 

The  cyst  may  exist  for  many  years  and  only  be  discovered  at  autopsy. 
The  great  danger  is  that  they  may  rupture.  However,  this  is  not  neces- 
sarily fatal  as  they  may  rupture  externally  or  into  the  intestinal  canal.  A 
cure  may  result  in  this  manner.  If  the  rupture  occurs  into  the  pleural  cav- 
ity, gall  bladder  or  paritoneal  cavity,  it  is  almost  invariably  fatal.  If 
infection  occurs,  the  disease  may  resemble  a  liver  abscess. 

Symptoms. 

The  symptoms  vary  according  to  the  size  and  location  of  the  cyst. 
When  large  and  near  the  surface  it  may  be  felt  as  a  globular  tumor,  rather 
elastic  and  sometimes  fluctuating.  If  the  tumor  is  behind  the  liver,  there 
may  be  no  symptoms  at  all.  Most  patients  complain  of  a  sense  of  distress 
and  weight  in  the  hepatic  region.  As  the  tumor  grows  there  may  be  pres- 
sure symptoms,  as  dyspnea  and  cough  from  extension  upwards  to  the  dia- 
phragm. Pressure  on  the  portal  vein  may  result  in  ascites,  jaundice  or 
hemorrhoids.  The  hydatid  fremitus  is  seldom  present.  It  is  only  pres- 
ent when  the  daughter  cysts  swim  in  the  fluid. 

Diagnosis. 

The  diagnosis  is  often  difficult  as  many  of  these  patients  may  re- 
main in  good  health  for  years.  It  may  be  differentiated  from  cancer  and 
abscess  by  the  long  history,  slow  growth,  the  absence  of  loss  of  weight  and 
the  lack  of  the  pronounced  constitutional  symptom  present  in  abscess.  Its 
shape  and  absence  of  biliary  symptoms  rule  out  gall  bladder  disease.  The 
fact  that  the  colon  does  not  overlie  the  tumor,  rules  out  cystic  or  sarcomatous 
kidney. 


642  SURGERY    OF    THE    GALL    BLADDER    AND    LIVER 

Treatment. 

The  treatment  consists  of  evacuation  of  the  cyst  contents  and  removal 
of  the  lining-  of  the  cyst  cavity  and  drainage  of  its  cavity,  or,  in  a  few 
selected  cases  where  the  cyst  is  pedunculated,  excision  of  the  entire  cyst. 

The  operation  of  drainage  of  the  cyst  may  be  done  in  two  stages,  after 
the  method  of  Vblkmann,  which  consists  of  opening  the  peritoneal  cavity 
and  placing  sterile  gauze  pads  between  the  cyst  wall  and  the  peritoneum 
to  cause  adhesions  to  form  between  the  liver  and  the  peritoneum,  or  suturing 
the  cyst  wall  to  the  peritoneum,  and  three  or  four  days  later  opening  and 
draining  the  cyst. 

The  operation  most  commonly  done  consists  of  making  an  incision  over 
the  most  prominent  part  of  the  swelling,  then  carefully  packing  away 
the  stomach  and  intestines  with  sterile  gauze  pads  ;  a  trocar  is  inserted  into 
the  cyst  and  as  much  fluid  as  possible  is  withdrawn.  The  cyst  is  then  in- 
cised and  the  remainder  of  its  contents  sponged  out.  The  lining  of  the 
cyst,  which  is  known  as  the  parasite  endocyst,  is  removed.  The  edges  of 
the  cyst  are  sutured  to  the  peritoneum  and  the  cyst  cavity  packed  with 
gauze. 

The    after-treatment    consists    in    gradually    diminishing    the    amount    ot 
packing  at  each  dressing  until  the  cyst  cavity  is  obliterated. 

INJURIES    OF  THE    LIVER. 

The  liver  is  apt  to  be  injured  by  crushing  accidents,  as  when  a  heavy 
wagon  wheel  passes  over  the  body ;  also  by  blows  or  falls  which  break  one  or 
more  ribs,  which  puncture  the  liver,  or  from  penetrating  wounds. 

The  symptoms  of  rupture  of  the  liver  are  those  of  internal  hemorrhage 
and  severe  shock,  such  as  extreme  palor  and  cold  skin,  feeble  and  rapid 
pulse,  sighing  respiration  ;  the  abdomen  becomes  swoolen  and  tympanitic  and 
sometimes  dullness  from  the  collection  of  blood.  Often  there  is  vomiting, 
thirst  and  syncope. 

Treatment. 

The  treatment  should  be  directed  toward  the  control  of  hemorrhage  as 
soon  as  possible  and  to  prevent  the  retention  of  bile  in  the  peritoneal  cavity 
on  account  of  its  liability  to  cause  cholemia. 

WOUNDS    OF    LIVER. 

If  from  the  site  of  injury  it  is  thought  that  the  injury  to  the  liver  is  in 
the  left  lobe,  or  is  undetermined,  it  is  well  to  make  a  median  incision. 

In  wounds  of  the  right  lobe  a  longitudinal  incision  is  made  through  the 
outer  edge  of  the  right  rectus  abdominus  muscle  and  then,  if  found  neces- 
sary, this  may  be  converted  into  the  "S"  shaped  incision,  as  suggested  by 
Bevan,  or  into  the  Robson  incision. 

Wounds  of  the  liver  may  be  treated  by  suture  or  cautery  or  by  gauze 
tampon,  or  by  suturing  a  piece  of  sterile  gauze  down  upon  the  bleeding 
surface. 

In  the  majority  of  cases  a  little  pressure  by  means  of  a  gauze  pad  for 
a  few  minutes  will  control  the  hemorrhage.  In  some  cases  it  may  be  neces- 
sary to  make  continuous  pressure  over  the  bleeding  surface.  This  may  be 
done  by  suturing  a  piece  of  iodoform  gauze  over  the  bleeding  surface  by  a 


PLATE  CVII, 
L.  Liver.     S.   Section  removed.      (Frank.) 


PLATE  CVIII. 
L.  Liver  with  wound  partially  sutured.     (Frank.) 


SURGERY    OF    THE    GALL    BLADDER    AND    LIVER  647 

few  catgut  stitches  and  bringing  one  end  up  through  the  abdominal  wall. 
The  gauze  will  make  continuous  pressure  and  the  stitches  will  prevent  the 
displacement  of  the  gauze  should  the  patient  cough  or  vomit.  The  catgut 
will  be  absorbed  in  a  few  days  so  that  the  gauze  may  then  be  readily  re- 
moved. Bleeding  may  also  be  controlled  by  suturing  the  liver,  using  a 
non-cutting  needle  threaded  with  catgut.  The  sutures  are  passed  directly 
through  the  liver  substance,  then  tied  just  tight  enough  to  bring  the  edges 
of  the  liver  together,  the  blood  pressure  in  the  liver  is  very  low  and  is  con- 
trolled by  slight  pressure. 

In  large  wounds  with  considerable  destruction  of  liver  tissue  it  is  better 
to  use  the  method  of  suture  as  devised  by  Frank.  This  consists  in  the  ex- 
cision of  a  portion  of  the  liver,  as  shown  in  Plate  CVII,  removing  a  wedge- 
shaped  piece,  leaving  the  organ  with  two  flaps  forming  a  trough.  If  there 
is  much  bleeding  from  the  cutting  of  the  liver  tissue,  it  is  controlled  by 
ligating  the  bleeding  vessel,  or  by  passing  a  matress  catgut  suture  through 
the  entire  thickness  of  the  liver  surrounding  the  vessel.  The  flaps  are  now 
coaptated.  For  this  purpose  a  long  non-cutting  needle  is  threaded  with 
catgut  and  a  running  stitch  is  commenced  at  one  end  and  continued,  as  fol- 
lows (Plate  CVIII)  :  One  suture  is  carried  through  the  liver  tissue  near  the 
bottom  of  the  trough  and  then  one  superficially,  and  so  on  alternating.  The 
stitches  should  not  be  tight,  but  drawn  just  enough  to  bring  the  two  tied 
flaps  together  in  perfect  coaptation,  obliterating  all  dead  space.  The  con- 
tinuity of  the  liver  surface  is  re-established  and  no  raw  surface  or  ragged 
edge  is  left. 


PART   VIII. 

SURGERY  OF  THE  GENITO-URINARY 

TRACT. 

In  considering  the  surgery  of  the  kidney  especial  stress  should  be 
laid  upon  diagnosis,  because  this  is  really  the  most  difficult  task  connected 
with  the  subject.  The  examination  of  urine  is  most  important,  but  it  does 
not  in  itself  result  in  a  definite  surgical  diagnosis.  The  presence  of  al- 
bumen, tube  casts  and  characteristic  epithelial  cells  from  the  kidney  indi- 
cate nephritis  in  one  or  both  kidneys,  but  it  does  not  make  a  surgical 
diagnosis.  The  presence  of  blood  or  pus  indicates  a  bleeding  or  suppurat- 
ing point  in  the  kidney,  the  ureter,  the  bladder  or  the  urethra,  but  again 
it  does  not  definitely  locate  the  diseased  region;  consequently  these  find- 
ings can  act  only  as  corroborative  evidence  and  serve  but  to  confirm  a 
diagnosis  made  without  their  aid.  Were  it  possible  to  obtain  the  urine 
from  each  kidney  separately  this  difficulty  would  in  a  measure  be  over- 
come, because  it  would  locate  the  source  of  these  substances  and  deter- 
mine the  diseased  organ.  At  the  same  time  it  would  be  possible  to  learn 
whether  the  other  kidney  was  sufficiently  active  to  be  depended  upon  to 
perform  the  entire  work.  In  the  female  this  can  be  done  with  comparative 
ease  through*  a  large  speculum,  the  patient  being  placed  in  the  knee-chest 
position  and  the  bladder  permitted  to  inflate  itself  with  air,  which  it  does 
spontaneously  whenever  a  speculum  is  inserted  with  the  patient  in  the 
position  named.  In  the  male,  it  may  be  accomplished  by  the  aid  of  a  cys- 
toscope. 

It  is,  however,  to  be  remembered  that  the  opening  of  the  ureter  into 
the  bladder  is  a  delicate  mechanism  which  frequently  prevents  infectious 
material  existing  in  the  bladder  from  infecting  the  ureter  and  the  kidney 
for  a  long  period  of  time,  and  also  that  in  cases  in  which  one  suspects  a 
diseased  kidney  the  bladder  is  very  frequently  not  aseptic  and  one  con- 
sequently runs  the  risk  of  infecting  the  other  kidney  also  by  carrying 
septic  material  from  the  bladder  into  the  ureter.  Moreover,  it  is  likely 
that  after  the  ostium  of  the  ureter  has  once  been  distended  for  the  intro- 
duction of  a  ureteral  catheter  it  may  no  longer  be  so  certain  to  guard 
against  infection  of  the  ureter  and  kidney  from  the  bladder.  A  num- 
ber of  surgeons  have  observed  infections  of  the  kidney  from  the  practice 
of  ureteral  catherization.  It  therefore  seems  at  the  present  time  to  be 
an  unwarranted  procedure,  except  in  the  hands  of  surgeons  especially 
trained  in  the  use  of  the  cystoscope  and  the  ureteral  catheter;  and  then 
only  when  needed  to  make  a  diagnosis  in  cases  in  which  a  positive  de» 
termination  is  of  importance  and  cannot  be  made  without  recourse  to 
this  method.  However,  quite  the  same  result  may  be  obtained  without 
disturbing  the  ureter  by  producing  a  peculiar  watershed  in  the  bladder, 
causing  the  urine  from  each  ureter  to  flow  into  a  separate  receptacle.  This 


650  SURGERY    OF    THE    GENITOURINARY    TRACT 

is  accomplished  by  means  of  the   Harris'   segregator,   which  is   illustrated 
in  Fig.  24.    The  use  of  the  instrument  is  described  by  Harris  as  follows : 

HARRIS  SEGREGATOR. 

"The  instrument  is  used  in  the  following  manner :  The  patient,  male 
or  female,  is  placed  comfortably  on  a  table  in  the  ordinary  lithotomy  po- 
sition, with  the  hips  slightly  elevated.  The  instrument,  with  the  flattened 
surfaces  in  contact  so  as  to  form  practically  a  single  catheter,  is  intro- 
duce^ into  the  bladder  in  the  ordinary  way.  As  soon  as  the  proximal, 
curved  extremity  is  within  the  bladder,  the  proper  distance  being  indi- 
cated by  the  gradual  scale,  each  catheter  is  rotated  about  its  longitudinal 
axis  until  each  proximal  end,  as  indicated  by  the  distal  end,  is  directed 
outward  and  backward.  The  end  of  each  catheter  should  pass  through 
an  arc  of  about  no  to  120  degrees,  or  so  that  the  angle  subtended  pos- 
teriorly by  the  two  catheters  will  be  about  120  or  140  degrees.  They  are 
held  in  this  position  by  a  small  spiral  spring.  The  ends  of  the  proximal 
extremity  will  now  be  in  the  neighborhood  of,  but  not  exactly  at,  the 
ureteral  openings.  The  ends  are  separated  a  greater  distance  than  the 
distance  between  the  ureteral  openings,  so  as  to  avoid  the  danger  of  com- 
pressing the  opening  of  the  ureter,  and  thus  preventing  the  escape  of  the 
urine.  The  lever  is  now  introduced  into  the  vagina  in  the  female  or  rectum 
in  the  male.  By  gentle  pressure  forward  directly  in  the  mid-line,  the  base 
of  the  bladder  is  raised  into  a  longitudinal  fold  between  the  ureteral  open- 
ings. 

The  curve  of  the  lever  is  such  that  it  fits  nicely  in  the  angle  formed 
by  the  separating  extremities  of  the  catheters,  thus  forming  a  complete 
watershed.  The  end  of  each  catheter  now  lies  at  the  most  dependent  part 
of  a  little  pocket,  a  perfect  watershed  separating  the  two.  The  ureters 
open,  one  on  either  side  of  the  watershed  near  the  base  of  the  declivity  in 
the  immediate  vicinity  of  the  respective  ends  of  the  catheter. 

By  producing  a  gentle  exhaustion  of  the  air  in  the  vials  by  means 
of  the  bulb,  the  urine,  as  fast  as  it  escapes  from  the  ureters,  drops  directly 
into  the  ends  of  the  catheters  and  flows  at  once  into  the  vials,  right  and 
left,  respectively. 

The  instrument  rind  its  application  are  so  simple  that  its  advantages 
are  apparent  at  once,  and  hence  need  no  arguments  to  support  them. 

This  being  the  case,  we  may  proceed  at  once  to  dispose  of  any  possible 
objections  that  may  suggest  themselves. 

The  possibility  of  compressing  the  opening  of  the  ureter  and  thus 
preventing  the  escape  of  the  urine  from  that  side  is  obviated,  as  already 
mentioned. 

In  diseased  conditions  of  the  vesical  mucosa  the  value  of  an  examina- 
tion may,  upon  first  thought,  appear  to  be  considerably  lessened,  owing  to 
contamination  of  the  urine  with  products  of  vesical  origin.  Upon  reflec- 
tion, however,  this  will  be  found  not  so.  The  bladder,  when  necessary, 
should  be  thoroughly  cleansed  by  irrigation  before  introducing  the  in- 
strument. After  the  instrument  is  in  place  the  little  pockets  may  be  again 
cleansed  by  irrigating  them  directly  through  the  little  straight  tubes  on 
the  distal  end  of  the  instrument  provided  for  that  purpose. 

The  urine,  as  fast  as  it  escapes  from  the  ureters,  is  sucked  at  once 
into  the  catheters,  so  that  it  docs  not  remain  in  contact  with  the  mucosa. 
The  end  of  the  catheter  is  so  near  the  opening  of  the  ureter  that  the  urine 


Fig.  24. 
HARRIS'  SEGRECATOR. 


SURGERY    OF    THE    GENITOURINARY    TRACT  653 

comes  in  contact  with  an  extremely  small  portion  of  the  bladder  surface. 
The  examination  is  not  continued  long  enough  at  any  time  for  pus  (for 
instance)  to  be  formed  in  sufficient  quantity  to  be  taken  up  by  the  catheter. 
Hence,  it  will  be  seen  that  contamination,  even  when  the  bladder  is  dis- 
eased, will  be  slight. 

It  is  likely  that  in  certain  greatly  enlarged  prostates  or  growths  of 
the  so-called  middle  lobe,  or  in  vesical  calculi  or  chronically  inflamed  and 
contracted  bladders,  the  instrument  would  not  be  applicable,  but  such 
cases  form  a  very  small  minority  of  those  in  which  its  use  would  be  de- 
sirable. 

The  little  straight  tubes,  when  not  being  used  for  irrigation,  must, 
of  course,  be  closed  air  tight  by  simply  tying  the  little  rubber  tubes  at- 
tached to  them,  or  passing  the  opposite  ends  of  a  single  tube  over  each 
straight  end.  Aspiration  with  the  bulb  should  not  be  too  great  so  as  to 
draw  the  mucosa  into  openings  of  the  catheter.  Very  slight  aspiration  is 
all  that  is  necessary.  As  a  few  drops  of  fluid  are  apt  to  remain  in  the 
bladder  even  after  the  use  of  the  catheter,  the  first  few  drops  that  come 
over  should  be  discarded. 

The  instrument  should  be  opened  carefully  when  in  the  bladder,  so  as 
not  to  excite  hemorrhage  by  injuring  the  mucosa.  The  proximal  curve 
should  be  just  within  the  bladder,  which  is  determined  by  noting  the  length 
of  the  urethra  on  the  scale.  Introduce  the  instrument  into  the  bladder 
and  open  it  before  introducing  the  lever  into  the  vagina  or  rectum.  The 
ends  of  the  catheters  are  easily  felt  through  the  vagina  or  rectum,  and  the 
lever  should  be  directly  in  the  middle,  midway  between  the  two  ends,  and 
pressed  snugly  into  the  angle.  Sufficient  pressure  should  not  be  used  to 
cause  pain,  as  the  watershed  is  very  easily  formed.  The  urine  does  not 
drop  continually  into  the  vials,  but  intermittingly,  just  as  it  escapes  from 
the  ureters.  The  use  of  the  instrument  is  not  painful  and  does  not  require 
an  anesthetic,  except  possibly  in  an  over-sensitive  or  nervous  patient,  who 
would  not  submit  to  any  manipulation  whatsoever. 

By  attention  to  these  simple  rules  the  application  of  the  instrument 
will  be  found  very  simple,  and  the  results  all  that  could  be  desired." 

The  instrument  is  contraindicated  only  in  cases  in  which  its  intro- 
duction is  likely  to  cause  severe  traumatism  on  account  of  the  inflamed 
condition  of  the  urethra  or  the  bladder.  These  cases  can  be  easily  elim- 
inated and  form  but  a  very  small  proportion  of  all  those  in  which  one 
might  desire  to  make  a  separate  examination  of  the  urine  from  the  two 
kidneys. 

Many  other  instruments  intended  to  accomplish  the  same  end  have 
since  been  invented  but  none  of  them  seem  to  be  as  reliable  as  the  Harris. 
Moreover,  the  number  of  men  who  can  safely  catheterize  the  ureter  has 
increased  to  such  an  extent  since  the  time  when  this  instrument  was  in- 
vented that  the  necessity  for  using  such  an  apparatus  is  no  longer  so 
marked. 

INFECTION  OF  THE  KIDNEY. 
Typical  History. 

The  patient,  a  married  woman  thirty  years  of  age,  gives  the  follow- 
ing history:  In  good  health  as  a  child.  Began  to  menstruate  at  four- 
teen ;  regular ;  painless.  Married  at  twenty-two.  Two  pregnancies  ;  labors 
normal.  Second  child  four  years  ago.  Has  never  felt  well  since.  She 
had  difficulty  in  emptying  the  bladder  after  the  child-birth.  On  the  eighth 


654  SURGERY    OF    THE    GENITOURINARY    TRACT 

day  after  confinement  she  was  taken  with  severe  pain  in  right  side  of  the 
abdomen,  which  lasted  for  about  three  months.  Since  then  has  had  nu- 
merous attacks  of  pain  in  the  same  region,  with  intervals  varying  from 
one  week  to  two  months.  Attacks  vary  in  severity.  Has  often  been  con- 
fined to  bed,  and  the  attacks  have  been  accompanied  by  fever  and  vom- 
iting. The  attack  lasts  from  a  few  hours  to  three  days.  The  patient  is 
often  jaundiced  during  these  attacks.  About  four  weeks  ago  this  patient 
was  taken  with  pain  in  the  right  side,  accompanied  by  a  severe  bearing- 
down  sensation.  At  this  time  she  noticed  a  mass  in  the  right  side  of  ab- 
domen the  size  of  an  orange.  Has  had  no  vomiting  and  does  not  think 
she  has  had  much  temperature  with  this  attack.  The  pain  has  been  almost 
constant  up  to  the  present  time,  but  the  tumor  has  decreased  somewhat 
in  size. 

Present  Condition. 

Greatly  emaciated,  appetite  good,  heart  and  lungs  normal.  Abdomen 
scaphoid.  A  fluctuating  mass,  somewhat  tense,  extends  from  the  right 
costal  arch  to  a  little  below  the  umbilicus  inward  to  the  median  line.  It 
is  plainly  palpable  on  bimanual  examination  with  one  hand  in  the  lum- 
bar region  and  one  on  the  abdomen.  It  is  quite  tender  and  seems  to  move 
slightly  on  deep  inspiration.  The  perineum  is  slightly  lacerated ;  cervix 
also  slightly  torn.  The  cervix  is  long  and  hard.  The  uterus  far  down 
in  pelvis,  normal  position,  fornices  empty,  adnexa  apparently  not  connected 
with  mass  above. 

During  the  paroxysms  or  periods  of  illness  there  is  always  an  increase 
in  the  size  of  the  swelling  and  a  decrease  in  the  flow  of  urine,  but  the  lat- 
ter is  less  turbid  at  such  times.  As  the  flow  increases  and  becomes  more 
turbid  the  patient's  condition  improves  and  the  swelling  decreases  in  size. 

The  heart  and  lungs  are  normal.  The  urine  contains  a  considerable 
amount  of  pus,  but  is  otherwise  normal.  Upon  examining  the  urine  from 
the  two  kidneys  separately,  by  means  of  the  Harris  segregator,  it  is  found 
that  the  fluid  secured  from  the  left  ureter  is  normal,  while  that  from  the 
right  kidney  contains  pus.  The  microscopic  examination  of  the  urine  has 
failed  to  demonstrate  the  presence  of  tubercle  bacilli. 
Diagnosis. 

The  swelling  is  located  in  the  vicinity  of  the  right  kidney  and  the  as- 
cending colon.  Frequently  an  appendix  is  located  as  high  up  and  some- 
times a  gall  bladder  is  located  as  low  down.  The  presence  of  jaundice  and 
the  persistent  gastric  disturbances  might  indicate  an  empyema  of  the  gall 
bladder,  or  gall  stones.  The  same  conditions  frequently  occur  in  the  case 
of  a  chronic  retro-cecal  appendicitis.  A  tuberculosis  of  the  ascending 
colon  with  adhesions  between  the  omentum  and  transverse  colon  might 
cause  the  same  symptoms.  The  two  elements,  however,  which  seem  to 
establish  the  diagnosis  are:  i.  The  fact  that  there  is  pus  in  the  urine 
coming  from  the  right  kidney,  and,  2.  The  fact  that  the  condition  is  evi- 
dently the  result  of  a  puerperal  infection  which  first  affected  the  bladder 
and  then  the  ureter,  and,  by  way  of  an  ascending  infection,  the  kidney. 
This  is  still  further  confirmed  by  the  regular  variations  in  the  size  of  the 
swelling  and  by  the  synchronous  changes  in  the  character  of  the  urine. 
The  patient  lived  in  a  small  town  in  the  mining  regions  at  the  time  of  her 
confinement,  where  she  could  not  obtain  medical  care  and  good  nursing; 
hence  it  is  likelv  that  there  remained  residual  urine  in  the  bladder  for  a 


PLAT  1C  CIX. 

Atrophy  of   kidney   structure   with  the   formation   of  a   large  cyst.     Dilatation   of 
the  ureter   from  obstruction. 


SURGERY    OF    THE    GENITOURINARY    TRACT  657 

considerable  time  and  that  the  pelvis  of  the  kidney  was  greatly  dilated  by 
the  return  pressure.  The  infection  of  the  pelvis  of  the  kidney  probably 
occurred  on  the  eighth  clay  after  confinement,  when  the  patient  suffered 
the  severe  pain. 

So  long  as  there  was  fairly  good  drainage  from  the  distended  pelvis 
of  the  kidney  through  the  ureter,  there  were  no  serious  symptoms,  because 
there  was  but  a  slight  amount  of  absorption,  the  pus  being  diluted  with 
urine  constantly  secreted.  But  as  soon  as  the  ureter  became  temporarily 
blocked  by  an  accumulation  of  thick  pus,  or  on  account  of  edema,  the  con- 
fined urine  became  more  septic  and  absorption  more  extensive.  The  in- 
creased pressure  increases  the  pain,  and  the  absorption  increases  the  tem- 
perature. The  gastric  disturbance  can  be  accounted  for  by  the  same  con- 
ditions. Jaundice  frequently  accompanies  abscesses  of  the  kidney  or  the 
appendix,  without  direct  involvement  of  the  liver  or  the  biliary  tract,  al- 
though these  parts  are  frequently  involved  secondarily.  The  most  impor- 
tant point  in  determining  the  differential  diagnosis,  however,  is  the  dem- 
onstration of  pus  in  the  urine  from  the  right  kidney,  and  normal  urine 
from  the  left.  We  can  consequently  make  a  positive  diagnosis  of  pus  in 
the  pelvis  of  the  right  kidney  without  being  able  to  positively  exclude  the 
presence  of  disease  in  the  vermiform  appendix,  the  gall  bladder  and  biliary 
ducts. 

The  disease  has  existed  for  four  years  and  the  history  of  the  case 
shows  that  the  infection  has  probably  extended  upward  through  the  ureter 
from  the  bladder.  It  is  difficult  to  determine  in  any  given  case  what  sec- 
ondary conditions  may  have  resulted  in  this  period  of  time.  The  fact  that 
aside  from  the  presence  of  pus  the  urine  is  nearly  normal  would  indicate 
that  no  great  amount  of  destruction  of  kidney  tissue  had  occurred,  but  that 
the  disease  is  chiefly  confined  to  the  pelvis  of  the  kidney. 

Obstruction  to  the  flow  of  pus  and  urine  from  the  right  kidney  dur- 
ing periods  of  exacerbation  of  the  disease  might  indicate  an  obstruction  of 
the  ureter  due  to  the  presence  of  a  renal  calculus,  which  could  readily  have 
formed  with  the  conditions  present  in  this  case,  or  an  occlusion  due  to  the 
presence  of  thickened  pus  or  to  an  edema,  or  to  an  acute  bend  in  the  ureter, 
or  through  the  presence  of  an  abnormally  placed  blood  vessel  compressing 
the  ureter.  In  case  the  obstruction  is  due  to  a  calculus  the  relief  which 
occurs  when  the  calculus  is  displaced  is  usuallv  much  more  sudden  and 
more  complete  than  it  was  in  this  case.  Obstruction  from  an  acute  bend 
of  the  ureter  occurs  only  in  cases  in  which  the  kidney  is  abnormally  mov- 
able, which  is  not  evident  in  this  patient.  However,  so  far  as  the  treat- 
ment and  the  prognosis  are  concerned,  it  is  immaterial  to  the  patient  wheth- 
er this  part  of  the  diagnosis  be  made  before  or  during  the  operation. 

Indications  for  Operation. 

It  is  plain  that  unless  this  patient  obtains  relief  from  her  present  condi- 
tion she  will  continue  in  her  downward  course,  which  has  become  more 
and  more  marked  as  time  has  progressed  during  the  past  four  years.  The 
constant  absorption  of  pus  will  not  only  continue  to  jeopardize  her  nutri- 
tion by  interfering  with  her  appetite  and  her  digestion  indirectly,  but  it 
will  undoubtedly  result  in  amyloid  degeneration,  especially  of  the  kidneys 
and  the  liver.  The  constant  presence  of  pus  in  the  bladder  is  likely  to  re- 
sult in  an  infection  of  the  pelvis  of  the  left  kidney,  which  has  as  yet  es- 
caped. Sooner  or  later,  the  tissues  of  the  kidney  itself  will  become  in- 


658  SURGERY    OF    THE    GENITOURINARY    TRACT 

flamed,  and  then  only  the  left  kidney  will  remain  to  perform  the  labor  of 
both  organs.  Aside  from  this  there  is  always  the  danger  of  metastatie  in- 
fection of  other  parts  of  the  body  from  the  presence  of  this  accumulation 
of  pus,  either  by  extension  or  by  metastasis,  because  this  is  possible  in 
case  of  an  accumulation  of  pus  in  any  part  of  the  body  if  the  drainage  is 
not  perfect.  The  only  way  in  which  relief  can  be  obtained  is  by  direct 
drainage  by  means  of  a  free  incision. 
Preparation  for  Operation. 

In  order  to  insure  against  an  accident  occurring  rather  frequently 
after  operations  upon  the  kidney — which  consists  in  a  complete  absence 
in  the  secretion  of  urine  by  both  kidneys  and  consequent  uremia — it  is 
wise  to  provide  for  very  free  elimination  before  the  operation  is  performed, 
first,  by  the  administration  of  cathartics,  and,  second,  by  having  the  pa- 
tient drink  great  quantities  of  distilled  water,  preferably  hot.  In  the  mean- 
time the  patient  is  placed  for  a  week  upon  a  simple  milk  diet. 

In  order  to  increase  the  activity  of  the  glands  of  the  skin,  she  will  re- 
ceive warm  baths  daily.  On  the  day  before  the  operation  two  ounces  of 
castor  oil  will  be  given  as  usual.  In  this  way  it  is  possible  to  place  the  pa- 
tient's kidneys  in  a  fairly  safe  condition  even  where  there  has  been  much 
impairment  of  their  function. 

Technique. 

The  operation  must  primarily  be  exploratory,  because  the  condition 
of  the  kidney  must  determine  the  course  to  be  employed.  If  the  condition 
of  the  kidney  is  such  as  to  preclude  the  possibility  of  its  restoration  to  nor- 
mal, as  a  result  of  a  conservative  operation,  then  its  removal  is  indicated, 
because  the  examination  with  the  Harris  segregator  has  demonstrated  the 
fact  that  the  left  kidney  is  normal.  On  the  other  hand,  if  it  is  possible 
to  preserve  the  kidney  this  must  by  all  means  be  done.  Were  the  other 
kidney  not  normal,  it  would  not  be  wise  to  remove  the  diseased  one,  so 
long  as  any  portion  of  it  remains  capable  of  excreting  urine,  even  though 
it  might  not  be  possible  to  obtain  a  perfectly  normal  kidney  as  a  result  of 
the  operation,  because  a  patient  can  live  longer  with  two  impaired  kidneys 
than  with  one. 

Were  this  patient  suffering  from  a  tuberculosis  of  this  kidney  our  po- 
sition would  be  quite  the  reverse,  because  then  we  would  remove  this  kid- 
ney even  though  it  might  not  be  seriously  diseased,  as  if  a  tuberculous  kid- 
ney is  simply  drained  the  other  kidney  is  almost  certain  to  become  in- 
volved, while  if  it  is  removed  the  physiologic  increase  in  the  circulation 
of  the  second  kidney  seems  to  overcome  a  slight  amount  of  tuberculosis 
after  the  first  kidney  has  been  removed. 

Beginning  at  a  point  near  the  twelfth  rib  an  incision  is  carried  down- 
ward toward  the  crest  of  the  ilium  through  the  edge  of  the  erector  spinae 
and  quadratus  lumborum  muscles,  being  careful  to  distinguish  the  ilio- 
hypogastric  nerve  and  to  retract  it  forward  in  order  to  avoid  injuring  it. 
It  is  well  to  make  a  free  incision  in  order  to  expose  the  kidney  well  for 
palpation  and  inspection.  This  exposes  the  fat  capsule  of  the  kidney. 
Were  we  not  practically  certain  of  the  presence  of  pus  in  this  kidney,  the 
condition  of  the  vermiform  appendix  and  the  gall  bladder  could  be  deter- 
mined with  ease  and  safety  by  perforating  the  peritoneum  in  front  of  the 
ascending  colon  and  making  a  digital  examination  of  these  organs. 

The  appendix  can  readily  be  removed  through  this  incision,  unless  it 


SURGERY    OF    THE    GENITOURINARY    TRACT  659 

is  too  extensively  adherent,  and  it  is  also  possible  to  remove  gall  stones 
from  the  gall  bladder  through  the  same  incision,  although  the  incision 
which  has  been  described  before  is  much  to  be  preferred. 

In  this  case,  however,  opening  of  the  peritoneum  would  not  be  proper, 
as  it  would  increase  the  likelihood  of  an  infection  of  the  peritoneal  cavity. 

The  fat  capsule  is  opened  and  a  dark,  oblong  organ  is  seen  in  the 
wound.  Grasping  this  between  the  fingers  it  is  found  to  fluctuate.  This 
is  undoubtedly  due  to  the  presence  of  pus  in  the  dilated  pelvic  cavity.  An 
incision  two  inches  in  length  is  made  through  the  cortex  of  the  kidney  a 
little  behind  the  center  of  its  convex  surface,  which  is  supposed  to  be  the 
least  vascular  portion  of  the  organ.  Immediately  there  is  a  free  flow  of 
pus  diluted  with  urine.  The  finger  is  inserted  into  the  pelvis  of  the  kid- 
ney and  this  cavity  is  carefully  palpated,  each  calix  being  explored  with 
the  finger,  in  order  to  determine  the  presence  of  a  renal  calculus.  The 
entire  pelvis  is  lined  with  granulation  tissue  and  there  is  a  considerable 
amount  of  thickening  of  the  tissues  of  the  pelvis.  The  cortex  of  the  kid- 
ney is  thin  and  somewhat  congested,  but  otherwise  normal.  A  large  probe 
with  a  bulbous  end  is  introduced  into  the  ureter  and  this  is  found  free 
from  obstruction  by  a  stone. 

A  catheter  is  now  introduced  into  the  bladder  through  the  urethra 
and  held  closed,  then  a  small  catheter  is  introduced  into  the  ureter  through 
the  kidney.  The  urine  is  permitted  to  flow  from  the  catheter  in  the  blad- 
der and  simultaneously  a  one-half  per  cent  solution  of  methyl  blue  is  in- 
jected into  the  other  catheter.  At  once  the  urine  takes  a  blue  color,  show- 
ing that  at  the  present  time  the  ureter  is  open. 

It  seems  likely  that  drainage  of  the  kidney  would  result  in  restora- 
tion to  a  fairly  normal  condition,  and  that  the  kidney  will  ultimately  be- 
come nearly  as  useful  as  its  fellow. 

In  order  to  stimulate  the  healing  of  the  pelvic  cavity,  and  at  the  same 
time  establish  free  drainage,  the  pelvis  will  be  tamponed  carefully  with 
iodoform  gauze.  A  rubber  drainage  tube  Avill  also  be  inserted  into  this 
cavity,  the  gauze  being  tamponed  around  this.  The  drainage  tube  and 
gauze  are  carried  out  through  the  wound  and  the  latter  is  sutured  above 
and  below  it.  A  large  dressing  applied  to  the  surface  completes  the  opera- 
tion. 

In  case  a  kidney  has  been  split  longitudinally,  as  in  this  case,  and  the 
pelvis  has  been  found  to  be  in  an  aseptic  condition,  which  is  not  infre- 
quently true  in  cases  in  which  a  uric  acid  or  an  oxalate  of  calcium  calculus 
is  found,  it  may  be  unnecessary  to  tampon  the  pelvis  of  the  kidney  with 
gauze.  In  these  cases  it  is  well  to  insert  a  Jacob's  retention  catheter  into 
the  lower  end  of  the  wound  and  to  suture  the  remaining  portion  of  the 
wound  with  catgut  suture  passed  through  layers  of  iodoform  gauze  placed 
upon  the  flat  surface  of  the  kidney  on  either  side  to  prevent  the  sutures 
from  cutting. 

After-Treatment. 

Occasionally  a  hemorrhage  occurs  upon  removing  the  tampon  which 
has  been  placed  in  the  kidney,  because  the  blood  vessels  in  this  organ  are 
characterized  by  especially  thin  walls,  making  their  closure  very  unstable. 
On  this  account  it  is  wise  to  postpone  withdrawing  the  tampon  until  it  has 
been  loosened  by  the  development  of  granulations.  It  may  be  removed 
a  little  at  a  time  until  it  has  all  been  loosened.  In  the  meantime  the  urine 


66o  SURGERY    OF    THE    GENITOURINARY    TRACT 

drains  through  the  wound  and  the  mucous  membrane  lining  the  ureter 
has  an  opportunity  to  become  normal,  because  the  flow  of  pus  and  urine 
through  this  canal  no  longer  causes  an  irritation. 

In  cases  like  the  one  instanced  the  urine  usually  becomes  clear  in  a 
few  days,  as  the  drainage  through  the  wound  is  so  free  that  there  is  no 
accumulation.  The  pelvis  of  the  kidney,  which  has  been  dilated  for  a  long 
period  of  time,  becomes  contracted  for  the  same  reason,  and  all  of  the 
conditions  become  more  nearly  normal  in  a  comparatively  short  period. 
It  is  wise  to  continue  the  drainage  until  there  is  no  doubt  but  that  the  pelvis 
of  the  kidney  and  the  ureter  are  nearly  normal,  so  that  natural  drainage 
will  be  established. 

Use  of  Distilled  Water. 

The  patient  should  receive  an  abundance  of  distilled  water  at  inter- 
vals of  one  to  two  hours  regularly,  in  order  to  dilute  the  urine,  which  will 
form  a  non-irritating  fluid  as  it  passes  over  the  diseased  surfaces.  In 
pyelitis,  and  in  fact  in  other  conditions,  such  as  renal  calculi,  in  which  the 
pelvis  of  the  kidney  is  diseased,  distilled  water  given  internally  in  consid- 
erable quantities  is  a  most  useful  remedy.  Many  patients  who  have  suf- 
fered for  years  from  renal  colic  are  permanently  and  perfectly  relieved  by 
this  simple  means.  It  seems  necessary  for  the  urine  to  possess  a  certain 
concentration  in  order  to  make  the  formation  of  renal  or  cystic  calculi  pos- 
sible in  the  absence  of  foreign  bodies,  which  may  account  for  the  clinical 
fact  that  has  just  been  described.  The  free  use  of  distilled  water  results 
in  diluting  the  urine  to  such  an  extent  that  renal  calculi  or  renal  sand  no 
longer  form.  Moreover,  the  urine  becomes  exceedingly  bland  and  non- 
irritating,  and  we  have  frequently  observed  not  only  a  relative  decrease 
of  the  pus  in  the  urine  from  dilution,  but  also  an  absolute  decrease,  as  a  re- 
sult of  drinking  distilled  water  freely. 

It  is  well  in  these  cases  to  administer  five  drops  of  dilute  aromatic 
sulphuric  acid  in  half  a  pint  of  distilled  water  every  two  hours,  especially 
if  there  is  a  tendency  to  the  precipitation  of  phosphates.  This  will  cause 
the  urine  to  remain  sufficiently  acid  in  reaction  to  keep  the  phosphorus  in 
solution. 

The  Formation  of  a  Fistula. 

In  case  the  ureter  does  not  become  normal  in  a  relatively  short  time, 
which  may  occur,  especially  where  the  disease  has  existed  for  a  long  time, 
the  wound  in  the  kidney  will  not  heal,  and  a  fistula  may  persist,  which  is 
not  only  disagreeable  because  the  dressings  are  constantly  wet,  but  which 
results  in  an  excoriation  of  the  skin  on  account  of  the  irritating  effect  of 
the  urine  with  which  it  is  constantly  in  contact.  In  these  cases,  it  is  ad- 
visable to  introduce  a  soft  rubber  retention  catheter  with  a  bulbous  end, 
preferably, — described  elsewhere  in  this  volume  as  a  Jacobs  catheter, — 
into  the  kidney  and  to  weight  the  free  end  by  inserting  a  glass  tube  into 
it  and  then  placing  this  in  a  bottle,  which  may  be  carried  underneath  the 
clothing,  suspended  from  a  belt.  At  night  a  longer  rubber  tube  is  at- 
tached to  the  catheter  and  its  free  end  is  passed  out  into  a  vessel  outside 
the  bed  on  the  floor.  This  tube  will  act  as  a  siphon  and  the  patient  will 
remain  entirely  dry.  Occasionally  the  ureter  does  not  recover,  and  then  it 
will  become  necessary  either  to  remove  the  kidney  or  to  be  satisfied  with 
the  drainage  which  has  been  established,  together  with  all  of  the  resulting 
inconveniences. 


Ureter 


Arxomcvlous  B  loocl-  vessels. 


PLATE  CX. 

Hydronephrosis  from  kinking  ureter  caused  by  anomalous  blood  vessels. 

(Mayo.) 


PLATE  CXI. 

Blood  vessels  cut  and  tied.     Fatty  facial  flap  raised  and  uretero-pelvic  junc- 
ture divided.      (Mayo.) 


SURGERY    OF    THE    GENITOURINARY    TRACT  665 

The  quantity  and  quality  of  urine  secreted  by  the  diseased  kidney 
can  now  be  easily  determined,  and  it  will  be  apparent  from  this  whether 
the  kidney  should  be  saved.  So  long  as  the  opening  into  the  kidney  is  too 
large  for  the  use  of  a  retention  catheter,  the  quantity  of  urine  can  be  de- 
termined by  weighing  the  dressings  before  they  are  applied  and  after  they 
have  been  in  place  for  a  given  time. 

It  is,  however,  not  safe  to  jwdge  of  the  condition  of  the  remaining 
kidney  by  the  amount  of  urine  secreted  into  the  bladder  from  it,  while  all 
of  the  urine  is  siphoned  out  through  the  catheter  in  the  diseased  kidney. 
In  one  instance  of  this  kind  in  which  we  removed  the  diseased  kidney  not- 
withstanding the  fact  that  but  180  cc.  of  urine  was  secreted  from  the  other 
kidney  the  latter  at  once  became  more  active,  secreting  400  cc.  on  the  third 
day  after  the  removal,  then  advancing  slowly  until  2,000  cc.  were  secreted 
daily  within  three  weeks,  then  very  gradually  reducing  to  1,500  cc.  when 
the  normal  amount  of  liquid  nourishment  and  water  was  taken.  The  case 
was  one  in  which  the  uterus  had  been  removed  for  carcinoma  in  a  very 
weak,  emaciated  patient.  The  lower  end  of  the  right  ureter  being  in- 
volved it  was  excised  with  the  cautery,  for  several  days  both  kidneys  se- 
creted a  normal  amount  of  urine,  one  secreting  into  the  vagina,  the  other 
into  the  bladder.  Then  the  one  secreting  into  the  bladder  produced  less 
and  less,  running  as  low  as  100  cc.  on  some  days.  The  patient's  condition 
became  worse  constantly.  At  the  end  of  six  weeks  she  seemed  in  a  hope- 
less state,  when  she  developed  a  pyelitis  and  we  were  forced  to  choose 
between  certainly  losing  her  from  the  pyelitis  with  uremia  and  losing  her 
most  likely  from  shock  and  uremia  after  a  nephrectomy. 

The  fact  that  the  left  kidney  had  secreted  normal  urine  directly  after 
the  hysterectomy  determined  us  to  make  a  very  rapid  nephrectomy,  with 
the  result  stated  above.  It  is  consequently  not  proper  to  judge  entirely  by 
the  quantity  the  other  kidney  secretes  under  these  conditions  as  regards 
its  ability  after  the  removal  of  the  diseased  kidney. 

We  have  also  been  able  to  confirm  the  observation  of  others  in  cases 
of  tuberculosis  of  the  kidney,  that  the  removal  of  one  kidney  would  result 
in  the  secretion  of  more  urine,  and  urine  of  a  better  quality,  by  the  other 
kidney  than  was  secreted  by  both  before  the  nephrectomy  was  made. 

In  case  of  intermittent  hydronephrosis,  whether  the  urine  be  clear  or 
mixed  with  pus,  it  is  always  important  when  the  kidney  is  first  exposed 
to  determine  the  character  of  the  obstruction.  If  this  is  due  entirely  to 
a  kinking  of  the  ureter  from  a  dropping  down  of  the  kidney  and  the  ureter 
is  not  equally  mobile  with  the  kidney,  simply  dividing  the  adhesions  hold- 
ing the  ureter  and  fastening  the  kidney  in  place  by  nephorrhaphy,  as  de- 
scribed elsswhere,  will  suffice.  If  the  ureter  is  bent  acutely  over  an  aber- 
rent  blood  vessel  the  latter  should  be  caught  between  two  pair  of  forceps, 
cut  and  ligated,  and  nephorrhaphy  should  again  be  performed.  If  the 
obstruction  is  due  to  a  deformity  of  the  pelvis  itself  then  a  plastic  opera- 
tion should  be  attempted,  as  originally  recommended  by  Fenger.  The 
method  developed  by  Mayo,  as  illustrated  in  Plates  CX  to  CXIII,  is  so  sat- 
isfactory that  we  give  it  in  full. 

NEPHRECTOMY. 

When  we  find  the  kidney  hopelessly  destroyed  by  infection,  or  a  ma- 
lignant growth  of  the  organ,  a  nephrectomy  can  be  done  through  the  same 


666  SURGERY    OF    THE    GENITOURINARY    TRACT 

incision  that  we  use  for  a  nephrotomy.  In  case  a  diagnosis  of  a  malignant 
growth  is  made  before  the  operation  is  begun,  we  prefer  the  anterior  in- 
cision along  the  outer  edge  of  the  rectus  abdominis  muscle.  The  incision 
may  be  prolonged  sufficiently  to  remove  a  kidney  under  any  condition  with- 
out the  necessity  of  pulling  upon  the  tissues.  In  difficult  cases  the  pos- 
terior incision  which  we  have  just  made  is  not  sufficiently  long,  even 
though  it  be  extended  from  the  ribs  to  the  ilium.  Aside  from  the  incision 
the  steps  of  the  operation  are  the  same.  The  kidney  is  carefully  loosened 
from  the  fat  capsule  in  non-malignant  cases.  Then  a  pair  of  clamp  for- 
ceps are  applied  to  the  vessels  entering  the  kidney.  These  forceps  should 
be  perfectly  reliable,  but  should  not  be  sharp  at  any  point,  in  order  not  to 
injure  the  vessels.  The  renal  veins  are  thin-walled  and  easily  injured,  con- 
sequently great  care  should  be  exercised  in  loosening  the  kidney.  Drag- 
ging upon  the  renal  vessels  is  dangerous,  for  the  veins  might  easily  be  torn. 
This  accident  is  somewhat  more  likely  in  removing  the  left  kidney  be- 
cause of  the  anatomical  peculiarity  of  the  right  renal  vein.  After  the 
forceps  have  been  applied  the  kidney  is  cut  away  by  severing  the  vessels 
just  as  they  enter  the  pelvis.  The  vessels  which  project  beyond  the  forceps 
are  now  picked  up  separately,  ligated  with  catgut,  then  a  general  ligature 
of  catgut  is  passed  about  the  entire  pedicle.  As  this  ligature  is  tightened 
the  forceps  are  loosened  so  as  to  permit  the  ligature  to  compress  the  ves- 
sels in  the  pedicle  to  the  fullest  extent.  In  this  way  each  vessel  is  ligated 
twice,  which  eliminates  the  danger  to  the  patient  from  the  slipping  of  a 
ligature.  It  is  important  to  apply  the  ligature  slowly  and  carefully  be- 
cause it  may  cut  the  wall  of  the  vein  and  cause  a  fatal  hemorrhage. 

If  the  kidney  is  small  the  ligature  may  be  applied  to  the  vessels  com- 
posing the  pedicle  before  the  kidney  has  been  removed,  without  first  ap- 
plying the  pressure  forceps.  In  other  cases  in  which  it  seems  difficult  to 
ligate  the  pedicle  after  the  pressure  forceps  have  been  applied  this  may  be 
avoided  by  simply  leaving  the  forceps  in  place  for  twenty-four  hours  and 
arranging  the  dressing  around  this  in  a  manner  to  prevent  pressure  upon 
the  handles  of  the  forceps.  These  forceps  are  loosened  twenty-four  hours 
after  the  operation  and  removed  twelve  hours  later  after  the  stump  has 
withdrawn  from  the  bite  of  the  instrument. 

This  method  has  been  so  much  more  satisfactory  in  our  practice  than 
ligation  of  the  pedicle  that  for  several  years  we  have  used  it  entirely  in  a 
large  number  of  cases,  and  have  never  had  an  unfavorable  effect.  We 
use  strong  but  quite  elastic  forceps,  finely  serrated,  with  perfectly  smooth 
ends.  We  always  apply  two  pair,  then  cut  the  pedicle  beyond  the  second 
pair,  then  remove  the  pair  farthest  from  the  kidney  and  leave  the  other  in 
place  so  that  the  pedicle  extends  about  one  cm.  beyond  the  grasp  of  these 
forceps. 

The  wound  is  sutured  down  to  the  forceps.  In  case  the  stump  has 
been  ligated  it  is  well  to  leave  a  wick  of  iodoform  gauze  in  the  wound  ex- 
tending down  to  the  stump,  which  may  be  removed  in  a  few  days  unless 
during  the  removal  of  the  kidney  the  wound  has  become  infected  with 
pus  spilled  from  an  abscess.  In  this  event  a  tubular  rubber  drain  should 
be  added  to  the  gauze  tampon. 

Both  the  preparatory  and  the  after-treatment  are  the  same  as  in  those 
cases  in  which  nephrotomy  is  performed.  It  happens  occasionally  that  the 
other  kidney,  which  was  fairly  normal  before  the  operation,  secretes  little 
or  no  urine  for  several  clays  afterwards.  This,  however,  is  not  so  com- 


i~*--1  -VJKTf    '£.     **>     ~    •  f 


PLATE  CXII. 
Plastic    operation    on    uretero-pelvic    juncture    completed.       (Mayo.) 


PLATE  CXI  It. 
Fattv  facial  flap  in  position  and  held  by  a  few  catgut  sutures.      (.Mayo.) 


SURGERY    OF    THE    GENITOURINARY    TRACT  671 

mon  if  elimination  has  been  favored  before  the  operation  by  the  use  of 
milk  diet,  cathartics  and  an  abundance  of  distilled  water  as  where  this  pre- 
caution has  not  been  taken. 

Relative  Anuria  After  Operation. 

Should  anuria  occur  subcutaneous  transfusions  of  a  quart  of  normal 
salt  solution  once  or  twice  a  day,  and  the  use  of  saline  cathartics  and  steam 
baths,  and  continuous  rectal  instillation  of  water  by  the  drop  method,  are 
indicated.  Some  of  these  patients  suffer  severely  from  nausea  or  vomit- 
ing, which  is  most  readily  relieved  by,  thoroughly  irrigating  the  stomach, 
through  a  siphon  stomach  tube,  with  normal  salt  solution  as  hot  as  it  can 
be  borne,  up  to  110°  F. 

The  hot  gastric  lavage  alone  is  sometimes  shortly  followed  by  the 
free  secretion  of  urine.  In  other  patients  the  same  results  may  be  obtained 
by  giving  a  warm  enema  of  one-half  pint  normal  salt  solution  every  hour, 
introducing  the  fluid  by  the  drop  method. 

From  internal  remedies  we  have  not  seen  much  benefit  in  such  cases, 
and  can  consequently  not  speak  of  them  confidently,  with  the  single  excep- 
tion of  freshly  prepared  infusion  of  digitalis  made  from  reliable  leaves. 

An  enema  of  warm  salt  solution  in  quantity  varying  from  eight  ounces 
to  one  pint,  to  which  from  ten  to  twenty-five  grains  of  sodium  acetate  has 
been  added,  frequently  increases  the  flow  of  urine  in  these  cases  in  which 
there  is  little  or  no  urine  excreted  for  some  hours  after  the  operation.  This 
may  be  administered  every  hour  at  first,  and  less  frequently  later  on. 

The  value  of  gastric  lavage  with  hot  normal  salt  solution  in  cases  in 
which  nausea  exists  is  certainly  very  great,  as  it  removes  a  quantity  of  de- 
composing mucus  from  the  stomach  and  supplies  fluid  for  the  purpose  of 
stimulating  diuresis.  \Yhen  given  as  hot  as  can  be  borne  and  repeated  fre- 
quently the  patient  usually  begins  to  perspire  freely  during  the  adminis- 
tration of  the  lavage,  and  this  in  itself  is  of  course  of  great  benefit.  Placing 
a  canvas  tent  over  the  bed  with  the  patient's  head  protruding,  and  filling 
this  tent  with  hot  air  generated  from  a  Bunsen  burner,  is  very  beneficial. 

Cystic  Kidney. 

Occasionally  a  kidney  containing  multiple  cysts  is  encountered.  Were 
these  in  only  one  kidney  a  nephrectomy  might  be  indicated  ;  but  as  it  is 
usually  present  in  both  kidneys  at  the  same  time,  and  as  there  is  conse- 
quently not  very  much  kidney  substance  left,  it  is  not  wise  to  do  a  nephrec- 
tomy in  such  cases,  because  the  operation  is  very  likely  to  give  the  patient 
no  relief,  and  usually  hastens  his  death.  It  seems  wiser  to  split  the  true 
capsule  of  the  kidney  throughout  its  length,  to  peal  it  back  on  each  side, 
and  cut  it  away,  and  possibly  to  make  crucial  punctures  of  the  superficial 
cysts.  This  will  relieve  the  tension  upon  the  remaining  kidney  tissue,  it 
will  improve  the  blood-supply  to  the  kidney,  and  will  not  reduce  the  amount 
of  kidney  tissue. 

This  method  has,  however,  not  been  sufficiently  tried  to  have  a  po- 
sition among  recognized  surgical  operations,  and  we  simply  mention  it  here 
for  want  of  a  method  we  can  recommend  from  personal  experience. 

If  the  kidney  contains  but  few  cysts  these  may  be  excised  without 
difficulty  and  with  safety  to  the  patient,  the  defect  being  closed  by  one  or 
two  catgut  sutures. 


672  SURGERY    OF    THE    GENITOURINARY    TRACT 

NEPHRORRHAPHY   FOR   THE  RELIEF  OF  MOVABLE   KIDNEY. 

Clinical  Case. 

The  patient  is  a  married  woman,  twenty-four  years  of  age,  the  mother 
of  two  children,  three  and  five  years  of  age.  She  gives  the  following 
history : 

Father  died  of  pulmonary  tuberculosis  ;  otherwise  the  family  history 
is  good.  The  patient's  health  was  good  until  one  year  ago,  when  she  took 
a  misstep  and  came  down  very  forcibly  on  one  foot.  From  that  time  on 
she  suffered  from  a  dragging  pain  -in  the  right  side  of  her  back,  just  be- 
low the  last  rib.  This  has  increased  constantly.  In  the  meantime  she  has 
also  become  very  nervous,  and  has  lost  her  former  vigorous  appearance. 
She  is  unable  to  do  housework  without  greatly  increasing  her  suffering. 
She  locates  her  pain  in  the  region  of  the  right  kidney.  There  are  no  di- 
gestive disturbances,  no  nausea  or  vomiting,  but  the  patient  suffers  greatly 
from  gaseous  distension  of  the  intestines. 

Present  Condition. 

The  patient  is  fairly  well  nourished  ;  her  appetite  is  fair ;  the  bowels 
are  regular.  Heart,  lungs  and  urine  are  normal.  The  right  kidney  can 
be  palpated  and  moved  beyond  the  median  line  and  down  opposite  the 
anterior  superior  spine  of  the  ilium.  It  can  be  carried  up  into  its  normal 
position,  and  when  it  approaches  this  point  it  slips  into  place  very  sudden- 
ly. When  it  is  out  of  place  the  space  which  it  should  normally  occupy  is 
found  vacant  upon  bimanual  palpation. 
Diagnosis. 

The  same  considerations  as  regards  the  differential  diagnosis  may  be 
applied  to  this  that  were  applied  to  the  previous  case.     The  only  condition 
with   which  a   movable  kidney   can   be  confounded,   in   a  case   like  the  one 
before   us,    is   a   pedunculated    hydrops   of    the    gall-bladder,   or   a   tongue- 
shaped  projection  from  the  right  lobe  of  the  liver,  known  as  Riedel's  lobe, 
or  a  tumor  in  a  very  movable  cecum  or  ascending  colon.     Once  we  encoun- 
tered a  carcinoma  of  the  pylorus  in  an   extremely  movable  stomach  which 
was  mistaken  for  a  floating  kidney.     Occasionally  a  gall  bladder  occluded 
by  a  gall  stone  will  become  distended  to  the  size  of  the  movable  mass  here 
found  without  becoming  adherent.     The  neck  of  the  gall  bladder  will  be- 
come stretched  and  the  latter  may  lie  movable  in  every  direction.     It  fre- 
quently falls  into  a  space  in   front  of  the  left  kidney  and  under  the  edge 
of  the  liver,  with  the  same  little   jerky  motion  that  one   feels  in   replacing 
a  movable  kidney.     The  thickness  of  the  abdominal  wall  will  make  it  im- 
possible to  observe  the  fluctuation   of  the  fluid  contained  in  the  gall  blad- 
der, and  it  mav  be  quite   impossible  to   make  a  positive  differential   diag- 
nosis  between    these   two   conditions   until    the   abdomen   has   been   opened. 
Another  condition  which  is  more  easily  differentiated,  but  which  occasion- 
ally   causes    difficulty,    is    a    tongue-like    projection    downwards    from    the- 
right  lobe  of  the  liver,  known   as    kiedel's  lobe    (mentioned  above).     This 
mav  be  from  six  to  eight  inches  in  length,  or  even  longer,  and  consequent- 
ly its  lower  end  can  l>e  dislocated  a  considerable  distance.     This  mass  is, 
however,  continuous  with  the  liver,  and  it  is  never  quite  as  movable  as  the 
mass   in   this   case,  and   it   is   always  only   its   lower  end   which  moves,   the 
upper  end   being   continuous   with   the   liver.      In   our   experience   this   con- 
dition has  alwavs  occurred  in  patients  with  thin  abdominal  walls  in  whom 


SURGERY  OF  THE  GENITOURINARY  TRACT  6/3 

a  diagnosis  could  be  made  after  a  careful  examination.  Should  it,  how- 
ever, exist  in  an  obese  patient,  such  a  definite  diagnosis  could  probably  not 
be  made. 

In  this  patient,  the  empty  space  which  exists  when  the  kidney  is  dis- 
placed is  so  distinct  that  there  can  scarcely  be  a  doubt  concerning  the  di- 
agnosis. 

Another  test  might  be  used  by  inflating  the  colon  with  gas  by  means 
of  an  air  pump  attached  to  a  tube  inserted  into  the  rectum.  The  distended 
colon  would  pass  below  the  mass  if  it  were  a  distended  gall  bladder  or  a 
deformed  lobe  of  the  liver,  while  it  would  pass  to  the  inner  side  of  the 
mass  if  it  were  the  kidney.  This  method,  although  theoretically  of  great 
value,  is  in  practice  useful  only  to  confirm  a  diagnosis.  If  too  much  weight 
is  placed  upon  this  method  the  surgeon  is  likely  to  err  in  his  diagnosis. 
Etiology. 

Aside  from  the  traumatic  cause,  we  have  here  the  history  of  two 
pregnancies,  which  is  another  common  cause  of  movable  kidney.  In  many 
of  these  cases  a  chronic  appendicitis,  gastritis,  enteritis  or  gall  stones,  or 
all  of  these,  exist  at  the  same  time,  and  it  is  difficult  to  say  whether  or 
not  there  is  any  casual  relation  between  these  various  conditions  or  wheth- 
er their  co-existence  is  merely  a  coincidence,  or,  again,  whether  they  are 
all  dependent  upon  an  infection  from  the  alimentary  canal. 

Many  years  ago  Pawlik  directed  our  attention  to  the  fact  that  of  the 
patients  coming  into  his  gynecological  clinic  of  all  women  who  did  the 
work  of  laborers  in  the  streets,  upon  buildings  or  on  the  farms  and  who 
had  borne  children,  seventy-five  per  cent  were  suffering  from  this  con- 
dition, but  that  of  all  such  there  were  but  a  few  in  whom  the  amount  of 
disturbance  caused  by  the  loose,  displaced  kidney  was  sufficient  to  require 
treatment.  Our  own  observations  have  confirmed  this  in  the  study  of 
many  hard-working,  foreign  women  who  came  under  care  for  the  treat- 
ment of  other  conditions,  and  in  whom  the  general  physical  examination 
revealed  the  presence  of  this  anomaly.  Scarcely  one  per  cent  of  all  pa- 
tients in  whom  the  kidney  is  movable  to  a  markedly  abnormal  degree  re- 
quire operation.  On  the  other  hand,  we  observe  twenty  cases  in  whom 
nephrorrhaphy  has  been  performed  without  the  slightest  benefit,  for  each 
case  in  which  the  patient  has  been  benefited  by  the  operation. 

Indications  for  Operation. 

In  the  presence  of  an  anatomical  lesion  which  may  be  easily  removed, 
to  which  the  patient's  suffering  is  directly  referred,  and  wherein  the  sud- 
den occurrence  apparently  initiated  the  pain,  there  can  scarcely  be  a  doubt 
regarding  the  indication  for  operation.  This  is  especially  true  in  patients 
who  are  not  otherwise  neurotic  and  who  were  in  good  health  before  the 
accident  occurred  which  loosened  the  kidney,  and  in  whose  case  there  is  no 
pending  question  of  liability  for  personal  injury.  All  of  these  matters 
must  be  carefully  considered,  because  otherwise  the  operation  must  become 
more  and  more  discredited. 

The  preparatory  treatment  should  be  the  same  as  for  ordinary  abdom- 
inal sections. 

Technique. 

The  same  incision  which  has  been  described  in  connection  with  the 
previous  case  will  be  made,  the  fatty  capsule  opened,  and  the  kidney  brought 
up  for  inspection.  It  is  quite  normal,  aside  from  the  fact  that  it  is  so 


674  SURGERY    OF    THE    GEN  I  TO-URINARY    TRACT 

freely  movable.  The  pelvis  is  not  distended  and  it  is  evidently  free  from 
infection. 

So  large  a  proportion  of  patients  suffering  from  movable  kidney  suf- 
fer also  from  chronic  appendicitis  and  gall  stones  that  we  usually  examine 
these  organs  at  the  same  time,  provided  the  kidney  is  free  from  infection. 
This  can  be  done  by  making  a  small  opening  in  the  peritoneum  in  front 
of  the  colon,  inserting  one  or  two  fingers  and  palpating  these  organs.  In 
this  case  we  find  the  gall  bladder  free  from  disease,  but  the  appendix, 
which  is  four  inches  in  length,  club-shaped  at  its  distal  end  and  constricted 
at  its  cecal  end,  contains  a  number  of  fecal  concretions.  We  will  bring 
the  appendix  and  the  lower  end  of  the  cecum  out  through  the  opening  in 
the  peritoneum  and  remove  the  former  by  the  method  described  in  the 
section  on  appendicitis.  The  opening  in  the  peritoneum  is  then  sutured 
with  catgut  and  the  operation  upon  the  kidney  is  proceeded  with. 

The  kidney  is  first  brought  out  of  the  wound,  as  shown  in  Plate  CXIV, 
then  its  capsule  is  split  longitudinally  a  distance  of  two  to  three  inches  and 
loosened  from  the  surface  of  the  kidney  a  distance  of  about  one  inch,  as 
shown  in  the  same  plate.  Next  a  strand  of  iodoform  gauze  is  passed  un- 
derneath the  lower  pole  of  the  kidney,  likewise  as  shown  in  the  same  plate, 
and  fastened  to  the  capsule  of  the  kidney  by  means  of  a  fine  catgut  suture 
on  either  side.  The  kidney,  together  with  the  attached  gauze,  is  then  re- 
placed in  the  body,  as  shown  in  Plate  CXV,  and  the  true  capsule  of  the 
kidney  is  sutured  to  the  fascia  of  the  quadratus  lumborum  muscle  by  means 
of  a  number  of  chromicized  catgut  sutures,  as  indicated  in  Plate  CXV.  A 
small  strand  of  iodoform  gauze  is  passed  down  to  the  denuded  surface  of 
the  kidney,  and  then  the  entire  wound  is  sutured,  with  the  exception  of 
the  space  occupied  by  the  strands  of  iodoform  gauze.  These  are  removed 
about  ten  days  or  two  wTeeks  after  the  operation ;  by  which  time  vigorous 
granulation  tissue  will  have  developed,  later  forming  connective  tissue  to 
keep  the  kidney  in  place. 

Many  surgeons  do  this  operation  without  the  use  of  the  gauze  and 
claim  equally  perfect  results,  hence  this  part  of  the  procedure  can  hardly 
be  considered  absolutely  necessary.  It  seems  as  though,  in  this  case,  the 
removal  of  the  appendix,  with  its  enterolhhs.  is  likely  to  give  the  patient 
quite  as  much  relief  as  the  nephrorrhaphy.  This  has  been  borne  out  In- 
cur clinical  observations.  Patients  in  whom  no  lesion  is  corrected  except 
the  movable  kidney,  rarely  make  a  satisfactory  recovery,  while  quite  the 
contrary  is  true  of  those  in  whom  some  other  important  lesion  has  been 
found  and  corrected. 

The  amount  of  displacement  which  we  have  found  in  this  case  might 
easily  have  caused  an  obstruction  of  the-  ureter  and  a  consequent  hydro- 
nephrosis.  This  may  occur  as  a  result  of  an  acute  bend  or  twist  in  the 
ureter.  In  either  event  simple  drainage  as  practised  in  the  case  described 
will  result  in  the  contraction  of  the  dilated  pelvis  of  the  kidney,  and  sus- 
pension of  the  kidney  in  its  normal  position,  according  to  the  method  just 
described,  will  prevent  the  obstruction  to  the  ureter  in  future;  conse- 
quently a  permanent  recover}-  may  be  expected  unless  ulceration  has  re- 
sulted from  the  distortion  of  the  ureter,  and  this  in  turn  produced  cicatricial 
constriction  forming  a  fibrous  stricture.  The  degree  of  constriction  will 
determine  the  form  of  treatment  in  such  cases,  [f  the  constriction  is  only 
moderate,  simple  drainage  of  the  hydronephrosis,  together  with  nephrorr- 
haphy, will  result  in  a  sufficient  degree  of  relief  to  promise  a  complete  re- 


PLATE  CXIV. 
NEPHRORRHAPHY. 

The  wound  in  the  lumbar  region  should  be  drawn  nearly  twice  as  long  as  shown 
in  the  figure.  The  kidney  has  been  delivered  through  the  lumbar  incision,  its  capsule 
has  been  split,  a  piece  of  iodoform  gauze  has  been  drawn  through  underneath  its  lower 
pole  and  has  been  fastened  in  place  by  means  of  two  sutures  through  the  capsule. 
The  capsule  has  been  separated  from  the  surface  of  the  kidney  for  a  distance  of 
eight  centimeters  in  length  and  three  centimeters  in  width. 


SURGERY    OF    THE    GENITO-URINARY    TRACT  677 

covery,  because  the  connective  tissue  will  become  softer  and  the  edema 
reduced,  and  consequently  the  passage  of  the  urine  through  the  ureter  will 
become  more  and  more  free  and  presently  all  of  the  urine  will  pass  in  the 
natural  way.  If,  however,  the  constriction  is  great,  nothing  less  than  a 
nephrectomy  will  usually  suffice  to  give  relief.  It  is,  however,  to  be  hoped 
that  in  the  future  plastic  operations  or  resections  of  the  ureter  will  yield 
more  satisfactory  results  than  at  the  present  time.  It  is  not  likely  that  dil- 
atation with  bougies  or  sounds  will  ever  accomplish  much  in  these  cases 
because  of  the  difficulty  one  encounters  in  introducing  bougies,  the  danger 
of  rupturing  the  thin-walled  ureter  and  the  danger  of  infection.  The  lack 
of  permanency  of  results  after  dilatation,  which  we  have  had  abundance 
of  opportunity  to  observe  in  the  dilatation  of  strictures  in  other  tubes  in 
the  body,  convince  us  that  dilatation  of  ureteral  strictures  must  be  looked 
upon  as  visionary  in  all  except  the  neurotic.  In  cases  of  congenital  or  ac- 
quired deformities  causing  obstruction  the  methods  already  described  are 
indicated. 

PLASTIC   OPERATIONS  ON      THE  PELVIS   OF  THE  KIDNEY. 

The  principal  conditions  requiring  plastic  operations  upon  the  pelvis 
of  the  kidney  are  strictures  of  the  ureter  at  its  junction  with  the  pelvis  of 
the  kidney,  closure  of  the  pelvis  after  removal  of  stones,  and  the  repair 
of  the  ureter  after  its  partial  or  complete  detachment  from  the  pelvis  during 
operations  upon  the  kidney.  Even  with  most  careful  suturing  of  the  pelvis 
of  the  kidney  one  is  apt  to  have  a  leakage  of  urine.  To  overcome  this  con- 
dition W.  J.  Mayo  has  devised  and  put  into  practice  a  method  of  utilizing 
the  fascia  which  is  closely  attached  to  the  kidney,  especially  about  the  pelvis, 
as  a  protection  to  the  suture  lines  in  that  part  of  the  kidney. 

In  plastic  operations  upon  the  pelvis  of  the  kidney  for  intermittent 
hydro-nephrosis  with  a  stricture  at  the  juncture  of  the  ureter  and  the  pelvis 
of  the  kidney,  the  operation  is  as  follows :  The  fatty  f ascial  flap  is  dissected 
back  as  shown  in  Plate  CXI.  A  longitudinal  incision  is  made  through  the 
ureteropelvic  juncture,  as  shown  in  Plate  CXI ;  this  incision  is  now  sutured 
transversely  with  fine  catgut  after  the  method  of  a  Hoenike  Mikulicz 
pyloroplasty  (Plate  CXIII)  ;  the  fatty  f  ascial  flap  which  was  reflected  in  the 
early  part  of  the  operation  is  now  sutured  back  in  place,  covering  over  the 
line  of  suture  uniting  the  pelvis  and  the  ureter.  Even  though  it  can  be 
seen  that  at  some  points  the  suture  in  the  pelvis  is  not  urine  tight,  yet  after 
the  fatty  fascia  flap  is  sutured  over  this  area,  primary  union  will  usually 
take  place  without  any  leakage  of  urine. 

In  operating  for  stones  in  the  pelvis  of  the  kidney  in  patients  whose 
kidneys  are  not  infected  enough  to  require  drainage,  the  incision  in  the 
pelvis  can  be  closed  without  any  leakage  of  urine.  In  cases  of  stone  in 
the  pelvis  it  will  usually  be  found  that  there  is  an  increase  in  the  fatty  tissue 
in  region  of  the  pelvis,  which  is  also  adherent  thereto.  In  these  cases  the 
incision  is  made  directly  through  the  fatty  tissue  and  the  pelvis  as  though 
they  were  one. 

After  the  stone  is  removed,  the  incisions  in  the  pelvis  and  in  the  fascia 
covering  are  p.utured  as  a  part  of  each  other,  with  a  row  of  fine  catgut.  If 
the  opening  in  the  pelvis  has  not  been  injured  during  the  removal  of  the 
stones,  this  one  row  of  sutures  will  usually  be  sufficient  to  prevent  leakage. 
If  the  opening  in  the  pelvis  has  been  torn  during  the  removal  of  the  stones, 


678  SURGERY    OF    THE    GENITOURINARY    TRACT 

making  an  irregular  edge,  the  opening  is  first  sutured  as  above,  and  then 
a  flap  of  the  fatty  fascia  can  be  made  and  turned  back  to  protect  the  line 
of  suture.  This  flap  does  not  need  to  be  sutured  tightly,  but  two  or  three 
catgut  stitches  are  placed  in  such  a  manner  as  to  keep  the  parts  in  apposition. 
A  cigarette  drain  should  be  carried  down  to  the  vicinity  of  the  suture  line 
and  left  in  the  wound. 

Complications  of  Floating  Kidney. 

A  considerable  proportion  of  patients  suffer  at  the  same  time  from 
other  intra-abdominal  diseases.  Many  of  them  have  at  some  time  suf- 
fered from  acute  appendicitis  complicated  with  peritonitis,  followed  by 
extensive  adhesions.  It  seems  reasonable  to  suppose  that  these  adhesions 
would  have  a  casual  relation  to  the  development  of  floating  kidney,  either 
by  producing  direct  traction  upon  this  organ  or  by  necessitating  an  ab- 
normal amount  of  intra-abdominal  pressure  to  force  the  intestinal  contents 
through  the  intestines  in  the  vicinity  of  the  appendix,  and  especially  through 
the  ileo-cecal  valve. 

To  force  the  intestinal  contents  through  the  ileo-cecal  valve  the  in- 
testine must  be  fairly  well  fixed  at  its  mesenteric  attachment,  as  is  the  case 
with  the  small  intestine  in  its  normal  condition  or  with  the  colon  when 
normal.  When  the  enteroptosis  obliterates  this  condition  and  adds  to  it 
the  actual  obstruction  caused  by  the  kinking  which  results  from  enterop- 
tosis and  adhesions  combined,  the  obstruction  may  of  course  be  extreme 
and  the  effects  of  all  of  these  complications  should  not  be  attributed  to  the 
fairly  inoffensive  loose  kidney. 

A  considerable  number  of  these  patients  also  suffer  from  gall  stones. 
It  is  difficult  to  establish  a  reasonable  casual  relation  between  these  two 
conditions,  although  such  a  relation  between  gall  stones  and  appendicitis 
is  much  easier  to  explain  and  it  is  possible  that  both  gall  stones  and  floating 
kidney  in  these  cases  are  secondary  to  appendicitis,  although  this  has  by 
no  means  been  proven.  The  frequency  of  these  two  complications  explains 
the  failure  in  obtaining  symptomatic  relief  in  many  patients  suffering  from 
floating  kidney  in  whom  the  anatomic  result  after  nephrorrhaphy  has  been 
perfect. 

DECAPSULIZATION    OF    THE    KIDNEY    FOR    CHRONIC    NEPHRITIS. 

\Yhile  speaking  upon  this  subject  it  seems  proper  to  describe  a  relatively 
recent  operation  upon  the  kidney  which  has  not  as  yet  earned  a  position 
among  recognized  operations,  but  which  seems  to  be  based  upon  reasonable 
principles.  "We  refer  to  the  operation  of  removing  the  true  capsule  of  the 
kidney  for  the  cure  of  chronic  nephritis. 

The  same  incision  is  made  as  in  nephrorrhaphy  ;  the  capsule  is  split  in 
the  same  manner  but  throughout  the  entire  convex  surface  of  the  kidney. 
It  is  then  carefully  stripped  down  on  either  side  and  cut  away,  leaving  the 
entire  surface  of  the  kidney  in  contact  with  the  surrounding  tissues.  It 
seems  that  new  blood  vessels  form  in  great  numbers  and  that  the  remnants 
of  kidney  tissue  which  have  not  yet  been  destroyed  by  the  disease  will  suffice 
to  carry  on  the  function  of  the  organ  to  a  very  marked  extent  after  this 
operation. 

As  we  have  stated  above,  however,  this  procedure  has  not  as  yet  passed 
through  a  sufficient  period  of  observation  to  be  established  as  a  recognized 


PLATE  CXV. 

NEPHRORRHAPHY. 

The  kidney  has  been  replaced,  its  lower  pole  being  supported  by  a  strand  of 
iodoform  gauze.  The  loosened  capsule  has  been  sutured  to  the  muscles  and  fascia  in 
the  lumbar  wound. 

Usually  the  number  of  sutures  used  in  attaching  the  capsule  to  the  fascia  is  greater 
than  shown  in  this  figure. 


SURGERY    OF    THE    GENITOURINARY    TRACT  68l 

operation.  Since  the  above  was  written  a  few  years  ago  the  method  has 
been  much  lauded  by  some  authors  and  thoroughly  condemned  by  others. 
The  prevailing  opinion  at  the  present  time  seems  to  be  that  in  cases  in  which 
the  nephritis  is  clue  to  obstruction  of  the  circulation  caused  by  malposition 
of  the  kidney  this  operation,  combined  with  nephrorrhaphy,  may  be  of  bene- 
fit. It  is  certain  that  in  such  cases  albuminuria  will  disappear. 

The  number  of  these  cases  is  so  small,  however,  that  it  is  not  of  very 
great  importance.  In  connection  with  Dr.  George  Suker  we  were  able  to 
demonstrate  that  in  no  case  in  which  there  existed  an  albuminuric  retinitis 
at  the  time  of  operation  was  any  permanent  improvement  obtained. 

RESECTION  OF  THE  KIDNEY. 

This  operation  is  but  rarely  indicated,  as  the  reason  for  which  one 
would  be  likely  to  perform  it  is  the  removal  of  tumors.  The  kidney  is  so 
seldom  the  seat  of  benign  tumors  that  this  condition  scarcely  deserves  con- 
sideration, the  small  benign  cyst  having  been  mentioned  before.  In  malig- 
nant disease  of  the  kidney  even  the  complete  removal  of  the  organ  promises 
but  little ;  hence  a  resection  wrould  almost  certainly  be  followed  by  a  rapid 
recurrence.  In  severe  crushing  injuries  a  resection  sometimes  becomes 
necessary.  In  these  cases  the  extent  of  the  excision  will  depend  upon  the 
degree  of  the  trauma.  It  should  be  in  the  form  of  a  wedge-shaped  piece  in 
order  to  permit  of  the  closure  of  the  defect. 

Sutures  are  likely  to  cut  through  the  kidney  tissue  if  applied  directly, 
but  if  passed  through  gauze  folded  upon  itself  from  two  to  four  times,  then 
through  both  edges  of  the  wound,  then  again  through  layers  of  gauze,  then 
back  in  the  opposite  direction,  they  can  be  tied  without  cutting.  These 
sutures  should  be  of  catgut  which  will  last  about  ten  days  before  being  ab- 
sorbed. The  strips  of  gauze  may  be  permitted  to  project  from  the  wound 
so  as  to  be  withdrawn  when  they  are  freed  by  the  absorption  of  the  catgut 
sutures. 

The  same  plan  may  be  employed  after  nephrotomy  if  the  hemorrhage 
is  so  severe  that  it  cannot  be  controlled  by  tamponing.  If  drainage  of  the 
pelvis  of  the  kidney  is  desired,  in  a  case  in  which  this  plan  is  indicated 
because  of  severe  hemorrhage,  one  or  two  rubber  drains  may  be  wrapped 
in  iodoform  gauze  and  inserted  into  the  pelvis  of  the  kidney,  and  then  the 
sutures  applied  as  before,  the  cut  edges  of  the  kidney  being  thus  pressed 
against  the  gauze  surrounding  the  rubber  drains. 

PYELOTOMY. 

In  case  a  stone  is  located  in  the  pelvis  of  the  kidney  the  diameter  of 
which  does  not  exceed  two  or  three  cm.,  it  can  usually  be  removed  by  split- 
ting the  pelvis  posteriorly  in  the  direction  of  the  ureter.  This  should  of 
course  not  be  done  if  the  stone  is  very  large,  with  sharp  projections  extend- 
ing into  the  calices,  because  in  such  case  the  injury  caused  is  much  greater 
than  it  would  be  after  splitting  the  kidney  longitudinally.  The  finger  should 
be  inserted  into  the  kidney  pelvis  through  the  opening  and  a  careful  search 
made  for  further  separate  stones.  The  stone  removed  should  be  examined 
to  determine  whether  any  fragment  has  been  broken  off  in  its  extraction. 
The  wound  should  be  drained  by  a  fine,  soft,  split,  rubber  drainage  tube,  and 
a  few  cigarette  drains  should  be  passed  down  to  the  kidney  pelvis  to  drain 
the  surrounding  loose  tissue. 


682  SURGERY    OF    THE    GENITOURINARY    TRACT 

In  all  of  these  cases  the  patient  should  permanently  drink  only  distilled 
water,  or  spring  water  which  is  practically  free  from  any  mineral  substances, 
because  in  this  way  recurrence  may  be  prevented. 

EXCISION   OF  THE  URETER. 

If  the  ureter  is  diseased  in  connection  with  the  kidney,  which  is  not 
uncommon  in  tuberculosis,  it  may  be  excised  by  following  it  from  above 
downward.  If  disease  of  the  ureter  is  diagnosed  before  the  operation  is 
begun  it  is  better  to  make  an  oblique  incision  so  as  to  carry  the  lower  end 
thereof  to  a  point  near  the  anterior  superior  spine  of  the  ilium,  provided 
the  posterior  incision  has  been  chosen.  If  the  anterior  incision  has  been 
selected  it  is  well  to  split  the  outer  edge  of  the  rectus  abdominis  muscle 
longitudinally.  This  incision  may  be  lengthened  to  suit  the  convenience  of 
the  operator.  When  the  bladder  is  reached  the  ureter  is  cut  off  and  a  small 
purse-string  suture  applied  to  cover  the  stump.  The  wound  is  then  closed 
with  two  or  three  rows  of  catgut  sutures,  unless  infection  has  taken  place 
from  an  ulcerated  ureter  or  from  pus  in  the  pelvis  of  the  kidney,  in  which 
event  the  wound  should  be  drained  with  iodoform  gauze  above  and  below 
and  the  intervening  portion  sutured  in  order  to  prevent  the  formation  of  a 
hernia. 

After  the  kidney  and  the  ureter  have  been  removed  the  suppuration  will 
subside  rapidly,  even  if  it  has  not  been  possible  to  effect  the  removal  without 
spilling  some  of  the  pus  contained. 

CALCULUS  IN  THE  URETER. 

The  symptoms  in  this  condition  at  the  time  the  patient  comes  under  the 
care  of  the  surgeon  usually  simply  consist  of  localized  pain,  but  there  is 
always  a  history  of  renal  colic  preceding  the  present  complaint. 

The  pain  may  be  at  any  point  in  the  course  of  the  ureter,  although  the 
calculus  is  practically  always  located  at  one  of  three  points,  viz.,  (i)  at  the 
beginning  of  the  ureter,  (2)  at  a  point  where  the  ureter  passes  over  the 
edge  of  the  iliacus  muscle,  and  (3)  just  before  the  ureter  empties  into  the 
bladder. 

The  stone  may  almost  always  be  located  with  the  X-ray,  provided  the 
intestinal  tract  has  been  thoroughly  emptied  by  the  use  of  castor  oil  and 
enemata.  and  of  course  provided  that  the  apparatus  and  technique  used  are 
good.  Occasionally  a  fecal  concretion  in  the  appendix  may  be  mistaken 
for  a  renal  calculus  in  the  skiagram,  and  at  times  a  calcareous  phlebolith 
has  been  so  mistaken.  Of  course  if  the  colon  has  not  been  properly  emptied 
hardened  fecal  masses  may  cause  a  shadow  which  will  be  mistaken  for  a 
calculus.  Then  again,  at  times  a  renal  calculus  mav  be  so  transparent  that 
it  will  not  cause  a  sufficient  shadow  to  be  recognized  on  the  plate. 

Ordinarily,  however,  this  method  of  diagnosis  is  eminently  satisfactory. 

Treatment. 

An  abdominal  incision  is  made  directly  over  the  seat  of  the  stone,  ac- 
cording to  the  plan  for  abdominal  incisions  as  indicated  in  Plates  XIII  and 
XIV.  The  peritoneum  is  split  longitudinally  over  the  ureter  then  the  latter  is 
lifted  into  view  and  the  surrounding  area  tamponed  away  with  moist  gauze 
pads,  then  a  longitudinal  incision  is  made  once  and  a  half  the  length  of  the 
diameter  of  the  stone  and  directly  over  the  most  prominent  portion  thereof, 


PLATE  CXVI. 
Anastomosis   of  the   ureter   hv    Van   Hook's   method. 


SURGERY    OF    THE    GENITOURINARY    TRACT  685 

in  order  that  the  stone  may  be  removed  without  crushing  or  tearing  the 
wall  of  the  ureter.  The  stone  is  then  lifted  out  and  the  edges  of  the  wall 
of  the  ureter  permitted  to  fall  together.  A  rubber  drainage  tube  with  a 
notch  cut  out  of  its  lower  end  is  now  placed  down  upon  the  ureter  at  the 
point  of  the  opening  and  held  in  position  by  a  fine  catgut  suture,  then  this 
tube  is  surrounded  by  four  or  five  cigarette  drains  which  are  all  permitted 
to  pass  out  of  the  abdominal  wound  with  the  rubber  tube. 

Should  the  ureter  be  enlarged  above  the  point  at  which  the  stone  was 
located  the  rubber  tube  is  carried  into  the  lumen  of  the  ureter,  but  if  there 
has  been  no  obstruction  this  is  not  necessary. 

SECTION  OF  THE  URETER. 
Van  Hook  Operation. 

If  the  ureter  is  cut  during  an  operation,  except  in  cases  in  which  this 
is  done  for  the  removal  of  a  malignant  growth,  an  attempt  should  be  made 
to  repair  the  damage  immediately.  If  the  section  is  at  any  point  more  than 
a  few  cm.  distant  from  the  bladder  it  is  best  to  telescope  the  upper  segment 
either  directly  into  the  lower  segment  or  through  a  lateral  incision,  accord- 
ing to  the  method  introduced  by  Van  Hook.  This  operation  consists  in 
passing  a  probe  into  the  upper  end  of  the  lower  segment  and  cutting  down 
upon  this  probe  one  and  one-half  cm.  lower  down,  making  a  lateral  slit  5 
mm.  in  length,  then  ligating  the  upper  end  of  the  lower  segment,  then  a 
fine  silk  suture  is  passed  through  one  edge  of  the  lower  open  end  of  the 
upper  segment,  then  both  threads  are  threaded  in  one  needle  which  is  passsd 
up  the  lumen  of  the  lower  segment  through  the  lateral  slit  and  out  through 
the  opposite  wall  one  cm.  beyond  the  distal  end  of  the  lateral  slit.  Thus  the 
lower  end  of  the  upper  segment  is  telescoped  into  the  lumen  of  the  lower 
segment  through  the  lateral  slit.  The  edges  of  the  slit  are  carefully  sutured 
to  the  side  of  the  upper  segment  as  shown  in  Plate  CXVI. 

In  case  the  section  has  occurred  within  a  few  cm.  of  the  bladder  the 
ureter  is  laid  bare  and  loosened  for  a  distance  of  two  cm.,  then  a  convenient 
point  is  chosen  in  the  wall  of  the  bladder  and  after  making  a  slit  in  the 
peritoneal  covering  the  bladder  wall  is  tunneled  obliquely  with  a  trocar.  The 
end  of  the  ureter  is  then  split  in  halves  at  its  distal  end  and  each  half  trans- 
fixed with  a  fine  silk  suture  both  ends  of  which  are  then  threaded  upon  a 
needle.  These  needles  are  passed  through  the  opening  made  by  the  trocar 
separately  and  then  the  wall  of  the  bladder  is  transfixed  one  cm.  to  each 
side  of  the  trocar  opening,  as  shown  in  Plate  CXVI. 

In  order  to  make  the  next  step  possible  a  sound  is  passed  into  the 
bladder  and  its  end  is  engaged  in  the  open  end  of  the  canula  of  the  trocar 
which  is  in  the  bladder  and  as  the  canula  of  the  trocar  is  withdrawn  the 
end  of  the  sound  is  passed  out  through  the  wall  of  the  bladder.  The  open 
end  of  the  ureter  is  then  threaded  upon  this  end  of  the  sound  and  as  the 
latter  is  again  drawn  into  the  bladder  the  end  of  the  ureter  is  slipped  in 
with  it,  when  the  two  threads  are  drawn  taut  and  tied.  The  bladder  wall  is 
sutured  with  a  few  very  fine  catgut  stitches  to  the  side  of  the  ureter  and  the 
peritoneum  is  closed  over  all.  A  retention  catheter  is  inserted  and  the 
patient  is  given  half  a  pint  of  distilled  water  with  five  drops  of  dilute 
aromatic  sulphuric  acid  every  two  hours. 

A  soft  rubber  drainage  tube  and  several  cigarette  drains  are  passed 
down  to  the  point  of  anastomosis  and  out  of  the  lower  angle  of  the  wound. 


686  SURGERY    OF    THE    GENITOURINARY    TRACT 

These  are  left  in  place  four  days  unless  leakage  occurs,  in  which  event  they 
are  left  ten  days,  unless  the  leakage  subsides  sooner.  The  catheter  is  left 
in  place  ten  days,  being  removed  for  two  hours  twice  each  day,  in  the  male, 
after  the  second  day.  In  the  female  a  Jacob's  retention  catheter  is  used 
which  need  not  be  removed  for  ten  days  unless  phosphates  accumulate  in  its 
lumen,  which  has  never  been  the  case  in  patients  who  received  the  aromatic 
sulphuric  acid  and  distilled  water,  as  indicated  above,  although  formerly 
\ve  had  much  annoyance  from  this  source. 

PERMANENT    URLTERAL   FISTULA. 

In  cases  in  which  a  large  portion  of  the  lower  end  of  the  ureter,  either 
on  one  or  on  both  sides,  has  been  destroyed  intentionally  or  accidentally,  it 
may  seem  wise  to  preserve  the  kidney  although  if  the  fellow  kidney  is 
normal  this  is  usually  not  necessary,  as  the  patient  loses  more  from  discom- 
fort and  the  danger  of  infection  than  he  gains  from  possessing  the  addi- 
tional kidney.  But  if  the  other  kidney  is  not  normal,  or  if  the  lower  portions 
of  both  ureters  have  been  removed,  as  is  commonly  the  case  in  excision  of 
the  bladder  for  carcinoma,  then  it  is  proper  to  provide  for  a  comfortable 
nreteral  fistula. 

For  a  time  it  seemed  as  though  this  could  be  accomplished  by  trans- 
planting the  ureter  into  the  sigmoid  flexure  of  the  colon,  but  all  of  the 
patients  died  of  ascending  infection  until  recently  when  animal  experiments 
seem  to  have  shown  that  bv  transplanting  the  ureter  into  the  sigmoid  by 
passing  obliquely  through  the  wall  and  then  between  the  muscular  and 
mucous  layer  for  a  distance,  and  then  permitting  the  end  of  the  ureter  to 
project  for  a  distance  of  one  cm.  beyond  the  mucous  membrane  into  the 
lumen  of  the  intestine,  this  accident  may  be  avoided.  Such  a  plan  of  opera- 
tion looks  reasonable  and  has  proven  satisfactory  experimentally. 

As  most  of  these  patients  die  from  a  recurrence  of  their  original  car- 
cinoma within  a  few  years,  it  seems  as  though  they  were  entitled  to  the 
comfort  which  this  operation  offers. 

We  have  not  had  an  opportunity  to  test  this  method  above  mentioned 
and  none  of  the  cases  in  which  it  has  been  employed  have  been  operated 
long  enough  to  represent  a  test,  hence  we  must  be  satisfied  for  the  present 
with  the  statement  as  given. 

Watson's  Device. 

Watson  invented  a  device  for  collecting  urine  from  ureteral  fistulae 
located  in  the  lumbar  region  which  works  well. 

The.  ureter  is  simply  passed  through  the  edge  of  the  quadratus  lum- 
berum  and  the  latissimus  dorsi  muscles  and  permitted  to  project  five  mm. 
beyond  the  skin  where  it  is  attached  with  tine  silk  sutures.  Watson's  device 
consists  of  a  box  with  a  drainage  opening  and  spout  to  which  a  rubber  tube 
is  attached  and  which  carries  the  urine  into  a  rubber  bag.  The  rim  of  the 
box  is  fitted  with  a  pneumatic  tube  which  adjusts  perfectly  against  the 
patient's  back.  The  box  is  held  tightly  in  place  by  a  broad  elastic  belt 
encircling  the  patient's  body.  The  pneumatic  edge  of  the  box  protects  the 
patient  against  barm  from  pressure  and  secures  his  comfort.  By  placing 
a  few  drops  of  formalin  in  this  receptacle,  and  having  two  of  these  so  that 
they  may  be  worn  on  alternate  days,  they  will  not  become  offensive.  This 
method  is  much  safer  than  the  other,  and  in  patients  not  operated  for  ma- 


SURGERY    OF    THE    GENITOURINARY    TRACT  687 

lignant  growths  it  seems  better  to  employ  this  plan  until  the  latter  class 
of  cases  has  definitely  demonstrated  the  safety  of  the  oblique  implantation 
of  the  ureters  into  the  sigmoid. 

Of  the  various  methods  which  have  been  recommended  that  described 
above  seems  to  promise  the  greatest  safety. 

EXSTROPHY  OF  THE  BLADDER. 

The  condition  of  exstrophy  of  the  bladder  is  so  distressing  that  wre 
describe  an  operation  which  promises  to  become  generally  adopted,  although 
our  personal  experience  is  still  too  limited  to  warrant  recommending  it  on 
that  ground  alone.  The  entire  number  of  cases  which  have  been  operated 
by  this  method  is  also  quite  small,  and  in  many  of  them  the  ultimate  result 
has  not  been  reported,  but  all  the  operations  which  were  in  use  before  the 
introduction  of  this  one  can  be  applied  in  only  a  small  number  of  patients 
and  do  not  promise  very  satisfactory  results  at  best,  while  this  procedure 
seems  so  far  to  lie  most  satisfactory. 

Since  the  above  was  written  we  have  performed  the  operation  six  times 
with  five  recoveries,  one  patient  having  died  from  peritonitis.  Another 
patient  died  two  years  later  from  strangulated  hernia,  two  are  still  well  and 
two  others  have  not  been  heard  from  and  the  sixth  case  died  from  nephritis. 
The  physician  caring  for  the  patient  considered  it  a  case  of  septic  nephritis 
due  to  ascending  infection.  The  death  occurred  after  an  illness  of  a  few 
weeks  and  after  the  patient  had  been  well  for  five  years  following  operation. 

Preparation  for  Operation. 

Two  days  before  the  operation  the  patient  is  given  two  ounces  of  castor 
oil,  in  order  to  remove  as  much  of  the  mucus  and  other  contents  of  the 
alimentary  canal  as  possible  with  slight  irritation.  From  this  time  on  until 
the  operation  is  performed,  the  patient  is  given  only  concentrated  sterilized 
food,  sn  as  to  leave  the  alimentary  canal  in  as  nearly  an  aseptic  condition 
as  can  be.  Xo  enema  is  given  until  the  patient  is  anesthetized;  then  the 
rectum  and  colon  are  very  thoroughly  irrigated  with  boric  acid  solution, 
and  after  the  water  returns  perfectly  clear  the  sphincter  ani  muscles  are 
stretched  gently,  but  very  thoroughly.  Then  the  rectum  is  once  more  thor- 
oughly irrigated.  The  patient  is  placed  in  the  Trendelenburg  position  and 
the  bladder  is  carefully  disinfected. 

Mydl's  Operation. 

The  bladder  is  loosened  from  the  abdominal  wall  throughout  the  entire 
distance,  two  fine  probes  are  inserted  into  the  ureters,  great  care  being  taken 
not  to  disturb  the  little  valve-like  openings  at  the  end  of  the  ureters.  Then 
an  elliptical  portion  of  the  bladder  wall,  from  two  to  three  centimeters  in 
diameter,  is  excised  in  such  a  manner  that  the  openings  of  the  ureters  are 
as  near  the  middle  of  this  portion  as  possible.  Care  must  be  taken  in  this 
step  of  the  operation  not  to  injure  the  ureters.  It  is  best  to  begin  the  incision 
below  and  then  lift  up  the  portion  of  the  bladder  and  to  observe  the  direc- 
tion in  which  the  probes  extend  into  the  ureters.  In  this  manner  injury  to 
the  latter  is  readily  avoided.  The  segment  of  the  bladder,  together  with 
the  ureters,  is  now  held  upwards,  the  urine  which  issues  from  the  ureters 
is  sponged  gently,  and  the  remaining  portion  of  the  bladder  is  rapidly  dis- 
sected away.  Then  the  sigmoid  flexure  is  brought  up  into  the  wound  and 
a  longitudinal  incision  made  through  the  middle  of  the  longitudinal  muscu- 


688  SURGERY    OF    THE    GENITOUR1 N ARY     TRACT 

lar  band,  two  centimeters  in  length.  The  segment  of  the  bladder  is  inserted 
into  the  colon  and  held  in  place  with  four  silk  stitches,  two  at  the  end  of 
the  longitudinal  incision  in  the  colon  and  one  in  each  edge  of  the  incision 
half  way  between  these  two  stitches.  Four  sutures  are  previously  placed 
in  the  wall  of  the  colon,  one  on  each  side  of  the  middle  of  the  incision  and 
one  just  beyond  the  end  of  the  incision,  to  be  utilized  for  the  purpose  of 
manipulating  the  intestine  while  the  segment  of  the  bladder  is  sutured  in 
placed.  The  first  row  of  sutures  is  passed  through  the  entire  thickness  of 
the  bladder  and  through  the  entire  thickness  of  the  intestine,  care  being 
taken  to  repeat  about  the  fourth  stitch  in  the  continuous  suture  in  order  to 
prevent  slipping — after  the  manner  described  in  the  section  on  intestinal 
surgery.  After  the  entire  segment  of  the  bladder  has  been  sutured  into  this 
opening,  with  the  mucous  membrane  facing  the  lumen  of  the  intestine,  a 
second  row  of  sutures  is  applied  which  penetrates  neither  the  portion  of  the 
bladder  nor  the  intestine,  but  simply  grasps  a  sufficient  amount  of  tissue  to 
bring  the  serous  surfaces  carefully  and  thoroughly  in  apposition  throughout 
the  entire  course.  The  intestine  is  then  dropped  into  the  abdominal  cavity. 
Care  must  then  be  taken  to  isolate  the  layers  of  the  abdominal  wall  because 
the  latter  is  bound  to  be  defective  in  these  cases,  and  if  this  precaution  is 
not  taken  a  ventral  hernia  is  very  likely  to  result.  This  condition  later 
resulted  in  the  formation  of  a  strangulated  hernia  in  one  of  our  cases  which 
eventuated  in  the  death  of  the  patient.  After  these  layers  have  been  care- 
fully isolated  the  abdominal  wall  is  closed  in  the  manner  described  in  the 
section  on  abdominal  surgery. 

It  is  of  great  importance  in  these  cases  to  strap  the  wound  thoroughly 
with  rubber  adhesive  straps,  in  order  to  remove  the  tension  as  much  as  pos- 
sible from  the  stitches  in  the  abdominal  wound.  It  is  also  important  to 
administer  for  the  first  two  weeks  after  the  operation  only  such  food  as 
will  give  rise  to  the  formation  of  as  little  gas  as  possible,  in  order  to  reduce 
the  strain  upon  the  stitches  of  the  abdominal  wound  to  a  minimum.  The 
stretching  of  the  sphincter  ani  muscle  in  the  beginning  of  the  operation  will 
aid  in  preventing  accumulation  of  gas  and  will  reduce  the  pressure  upon 
the  wound  in  the  intestine.  Should,  however,  the  sphincter  contract  sooner 
than  desirable  a  rectal  tube  should  be  inserted  and  kept  freely  open,  in  order 
to  prevent  the  accumulation  of  flatus  in  the  rectum. 

These  patients  are  very  comfortable  after  the  operation.  They  are 
able  to  remain  perfectly  dry,  sleep  all  night  and  evacuate  the  urine  from  the 
rectum  as  often  as  they  would  normally  evacuate  the  bladder.  They  are 
no  longer  offensive  to  themselves  or  their  friends  and  neighbors  and  they 
and  their  families  look  upon  the  operation  as  a  great  blessing. 

It  is  important  not  to  injure  the  ostium  of  the  ureter,  and  for  this 
reason  the  probes  which  are  used  for  marking  the  location  of  the  ostium 
and  of  the  ureter  during  the  operation  should  be  manipulated  with  great 
gentleness.  It  is  undoubtedly  bad  practice  to  leave  ureteral  catheters  in  place 
for  several  days  after  the  operation,  as  recommended  by  some  surgeons, 
because  this  would  surely  injure  the  delicate  valve-like  openings. 

Were  is  not  for  these  delicate  structures  it  seems  unlikely  that  the 
operation  could  have  proved  satisfactory,  although  the  oblique  submucous 
implantation  of  the  ureters  may  prove  to  be  satisfactory  in  time. 


PLATE  CXVII. 
REMOVAL  OF  PENIS  AND  SCROTUM  FOR  CARCINOMA. 

With  excision  of  inguinal  lymphatics  and  transplantation  of  stump  of  urethra 
into  perineum,   showing  primary   incision 


PLATE  CXVIII. 

COMPLETE  EXCISION  OF  MALE  GENITALIA  FOR  CARCINOMA  OF  PENIS. 
I,  urethra;  2,  vascular  portion  of  penis;  3,  vessels  of  cord;  4,  vas  deferens. 
Showing  urethral  stump  transplanted  into  perineum  through  buttonhole,  the  end 
projecting  5  m.  m. 


PLATE  CXIX. 
COMPLETE  EXCISION  OF  MALE  GENITALIA. 

Together  with  inguinal  lymphatics  and  with  transplantation  of  stump  of 
urethra  into  perineum  through  button-hole  in  skin,  i,  urethra;  5,  fascia  of  in- 
ternal oblique  abdominal  muscle ;  6,  internal  oblique  abdominal  muscle ;  7,  Pou- 
part's  ligament. 


PLATE  CXX. 
COMPLETE  EXCISION  OF  MALE  GENITALIA  FOR  CARCINOMA  OF  PENIS. 

Together  with  excision  of   lymphatics  of  inguinal   region  and  transplanta- 
tion of  stump  of  urethra  into  perineum  through  button-hole  in  skin.     Operation 

completed. 


SURGERY  OF  THE  GENITOURINARY  TRACT  697 

PLASTIC  OPERATIONS  FOR  CLOSING 
THE  EXSTROPHY. 

In  performing  a  plastic  operation  for  the  purpose  of  closing  an 
exstrophy  of  the  bladder  everything  depends  upon  the  amount  of  tissue 
that  is  lacking  and  the  portions  involved.  Each  operation  must  be  planned 
with  a  view  to  the  formation  of  a  bladder  lined  with  mucous  membrane, 
that  will  hold  the  urine  or  that  will  serve  to  direct  the  flow  of  urine  into  a 
rubber  urinal.  If  possible  a  urethra  should  also  be  constructed.  Usually 
several  operations  are  required  and  then  the  results  are  as  a  rule  only  slightly 
satisfactory. 

Of  the  plastic  operations  we  have  obtained  the  most  satisfactory  result 
in  a  case  in  which  we  utilized  the  mucous  membrane  of  the  trough-like 
urethra  in  a  case  of  hypospadias  for  the  construction  of  a  urethra  which 
we  passed  out  through  a  large  trocar  puncture  in  the  urethra.  We  then 
made  an  incision  between  the  mucous  lining  of  the  bladder  and  the  skin  and 
then  closed  the  defect  by  bending  the  pieces  upward  and  suturing  into 
this  defect.  A  retention  catheter  was  placed  into  the  bladder  through  the 
new  urethra  and  aromatic  sulphuric  acid  in  distilled  water  was  given  every 
two  hours.  The  patient  made  a  very  satisfactory  recovery. 

The  boy  was  only  six  years  old  and  the  operation  was  performed  but 
one  year  ago.  How  the  organ  will  functionate  later  in  life  is  of  course  of 
much  interest. 

AMPUTATION    OF   THE    PENIS. 

This  operation  is  done  only  for  the  relief  of  malignant  growths  which, 
in  our  experience,  have  always  been  carcinomatous  in  nature,  although  there 
is  no  reason  why  other  forms  of  malignant  growth  should  not  occur  in  this 
organ. 

If  the  disease  is  confined  to  the  distal  end,  it  may  be  so  circumscribed 
as  to  be  completely  removable  by  the  amputation  of  only  a  portion  of  the 
organ,  but  if  any  doubt  exists  it  is  much  safer  for  the  patient  to  make  the 
complete  amputation  at  once,  together  with  a  thorough  removal  of  the 
inguinal  lymphatic  glands. 

If  the  condition  present  seems  to  warrant  the  removal  of  only  a  portion 
of  the  organ,  the  following  method  should  be  employed : 

A  small  rubber  tube  is  stretched  and  passed  several  times  around  the 
penis  near  its  pubic  attachment  and  then  tied,  in  order  to  make  the  operation 
bloodless.  A  point  is  then  chosen  sufficiently  far  from  the  tumor  to  insure 
freedom  from  invasion.  Usually  this  distance  should  be  at  least  five  centi- 
meters ;  and  the  greater  the  distance  the  better,  as  these  growths  are  exceed- 
ingly prone  to  recur  in  this  region.  After  the  point  for  amputation  has 
been  chosen  the  skin  is  divided  with  a  circular  incision  two  centimeters 
nearer  the  pubis.  Then  a  sound  is  introduced  into  the  urethra  and  a  catgut 
suture  is  passed  around  each  corpus  cavernosum,  and  another  around  the 
corpus  spongiosum  down  to,  but  not  through,  the  urethra,  which  may  be 
determined  by  the  presence  of  the  sound  in  the  canal.  These  ligatures  are 
carefully  tied.  Then  a  circular  incision  is  carried  down  to,  but  not  through, 
the  urethra,  one  centimenter  away  from  the  point  at  which  the  ligatures 
have  been  applied,  in  a  distal  direction.  Then  the  tissues  are  stripped  from 
the  urethra  for  a  distance  of  one  centimeter  in  the  distal  direction,  and  then 
the  urethra  is  severed. 


698  SURGERY    OF    THE    GENITOURINARY    TRACT 

The  dorsal  artery  is  now  caught  separately  with  hemostatic  forceps 
and  ligated.  Then  the  elastic  constrictor  is  removed  and  the  stump  will  be 
found  entirely  free  from  hemorrhage.  The  projecting  portion  of  the  urethra 
is  then  split  laterally,  and  carried  through  a  buttonhole  in  the  anterior  skin 
flap,  where  it  is  sutured  in  place  with  horse-hair  sutures.  The  skin  is  then 
drawn  over  the  stump  of  the  penis,  and  a  tenaculum  is  applied  on  each  side, 
thus  forming  a  transverse  wound.  The  edges  of  the  skin  are  united  and  a 
complete  covering  of  the  stump  is  formed  in  this  manner.  The  arrangement 
of  the  flaps  at  the  end  of  the  urethra  will  prevent  the  contraction  of  the 
canal  at  this  point. 

This  operation  leaves  the  patient  in  a  very  comfortable  condition,  but 
unfortunately  these  sufferers  do  not  come  under  the  care  of  the  surgeon 
early  enough,  as  a  rule,  to  make  the  procedure  justifiable.  Unless  the  case 
is  .absolutely  incipient  we  never  advise  this  operation,  because  it  is  almost 
always  followed  by  recurrences,  and  unfortunately  in  the  recurrent  cases 
the  disease  has  often  advanced  so  far  that  complete  excision  is  no  longer 
possible,  while  if  the  extensive  operation  described  below  is  done  fairly 
early  the  relief  is  very  likely  to  be  permanent. 

Fortunately  the  more  complete  operation  gives  satisfactory  results, 
both  as  regards  permanency  of  cure  and  function  of  the  urethra,  even  in 
advanced  cases.  This  operation  is,  however,  much  more  extensive  and  cor- 
respondingly more  severe  as  regards  the  production  of  shock.  It  contem- 
plates the  removal  of  the  entire  organ,  together  with  the  scrotum,  with  its 
contents,  and  the  tissues  of  the  spermatic  cords,  as  well  as  the  inguinal 
lymphatic  glands.  It  also  includes  the  transplantation  of  the  remnant  of 
the  urethra  into  the  perineum. 

Technique. 

An  incision  is  begun  opposite  the  internal  abdominal  ring  on  one  side. 
It  is  carried  down  over  the  center  of  the  inguinal  canal  around  the  edge  of 
the  scrotum,  sufficient  skin  being  left  to  insure  the  covering  of  the  entire 
defect.  Then  the  incision  is  carried  up  on  the  opposite  side  along  the  edge 
of  the  scrotum  over  the  inguinal  canal  to  a  point  opposite  the  other  internal 
abdominal  ring.  A  transverse  incision  is  made  to  join  the  two  here  de- 
scribed, just  below  the  pubis.  The  skin  and  superficial  fascia  are  then  dis- 
sected up  and  all  the  inguinal  lymphatic  glands  carefully  excised.  The 
tissues  of  the  cord  are  then  isolated  and  treated  as  described  in  the  operation 
for  castration.  The  bleeding  vessels  are  carcfullv  caught  with  hemostatic 
forceps,  in  order  to  reduce  the  loss  of  blood  to  a  minimum.  It  is  desirable 
to  make  a  very  thorough  dissection  of  the  entire  inguinal  region,  so  that  no 
infected  lymphatic  glands  remain.  The  suspensory  ligament  is  severed  from 
its  attachment  to  the  pubic  bone  and  then  the  crura  are  loosened  from  their 
attachments  to  the  rami  of  the  pnbes. 

It  now  becomes  necessary  to  insert  a  sound  into  the  urethra,  and  the 
latter  should  be  dissected  out  to  a  length  so  as  to  project  half  a  centimeter 
beyond  the  level  of  the  lateral  skin  flaps.  After  isolating  this  length  of 
urethra  it  is  cut  off  at  right  angles,  and  now  the  remaining  tissues  are 
loosened  from  their  attachment  backward.  The  branches  of  the  internal 
pubic  arteries  should  be  caught  before  they  are  severed,  because  quite  a 
little  blood  may  lie  saved  in  this  manner.  All  the  blood  vessels  are  then 
carefully  ligated.  The  remnant  of  the  urethra  is  split  anteriorly  and  pos- 
teriorly to  a  distance  of  one-half  centimeter,  and  is  sutured  directly  into  the 


PLATE  CXXI. 

HYPOSPADIAS  OPERATION. 

Fig.  1  represents  the  flaps  of  the  foreskin  reflected ;  the  urethra  carefully  dissected 
free ;  a  perforation  has  been  made  through  the  glans  by  means  of  a  trocar ;  the 
end  of  the  urethra  has  been  caught  with  fine  pointed  haemostatic  forceps  and  carried 
forward  through  the  opening  in  the  glans. 

Fig.  2  represents  the  flaps  sutured  in  place,  making  an  artificial  frenulum,  the 
end  of  the  urethra  having  previously  been  sutured  in  position  a  little  above  the 
center  of  the  glans. 

Taken  from  Dr.   C.   H.   Mayo's  original  drawings. 


II 

PLATE  CXXII. 

HyPOSPADIAS. 

Fig.  I  represents  the  prepuce  and  a  portion  of  the  skin  from  the  dorsal  surface 
of  the  penis  dissected  up  and  formed  into  a  canal,  with  the  cuticle  turned  in  for  a 
lining.  The  urethra  is  indicated  by  dotted  lines.  It  opens  on  the  inferior  surface 
of  the  penis. 

Fig.  II  represents  the  glans  and  the  penis  tunneled  and  the  newly  formed  urethra 
drawn  through  and  the  defect  upon  the  dorsal  surface  of  the  penis  closed  with 
sutures. 

Taken  from  Dr.   C.  H.   Mayo's  original  drawings. 


(a) 


PLATE  CXXIII. 
C.   H.    Mayo   method. 


(b) 


PLATE  CXXIV. 
C.   H.   Mavo   method. 


(d) 


PLATE  CXXV. 
C.   H.   Mayo   method. 


(g) 


on 

PLATE  CXXVI. 
C.   H.   Mayo   method. 


(i) 


PLATE  CXXVTI. 
C.   H.   Mayo  method. 


(1) 

PLATE  CXXVIII. 
C.   H.   Mayo  method. 


Cm) 


(n) 


PLATE  CXXIX. 
C.   H.   Mayo   method. 


(p) 

PLATE  CXXX. 
C.   H.    Mayo   method. 


SURGERY    OF    THE    GENITO-URINARY    TRACT  719 

lower  edge  of  the  wound  in  the  perineum.  A  small  retention  catheter  is 
introduced  into  the  bladder  and  the  incisions  in  the  skin  are  closed  through- 
out with  sutures.  If  the  dissection  in  the  inguinal  region  has  been  quite 
extensive  it  is  well  to  insert  a  small  split  rubber  drainage  tube  on  each  side, 
in  order  to  prevent  the  accumulation  of  serum.  Ordinarily,  however,  the 
application  of  thoroughly  fitting  pads  will  make  this  unnecessary.  An  ordi- 
nary dressing  is  applied  to  the  wound  and  a  retention  catheter  is  attached 
to  a  rubber  drain,  which  is  inserted  in  a  bottle  containing  some  antiseptic 
fluid. 

This  operation  is  usually  performed  in  aged  patients,  and  consequently 
it  is  important  that  it  should  be  done  quickly  and  that  as  little  traumatism 
as  possible  be  inflicted. 
After-Treatment. 

We  have  found  it  advantageous  to  permit  these  patients  to  sit  up  soon 
after  the  operation,  on  the  second  or  third  day,  because  this  will  not  interfere 
with  the  healing,  and  because  they  are  prone  to  hypostatic  congestion,  which 
can  be  avoided  in  this  manner. 

The  retention  catheter  is  removed  on  the  second  or  third  day  and  the 
patient  permitted  to  evacuate  his  bladder  spontaneously.     In  some  cases  we 
have  permitted  this  from  the  beginning  with  perfect  satisfaction. 
Prognosis. 

Our  personal  experience  with  this  operation  has  been  confined  to  six 
cases,  all  of  which  had  been  previously  operated  for  the  relief  of  carcinoma, 
and  in  all  of  them  there  was  not  only  a  recurrence  of  the  disease  in  the 
organ,  but  also  a  recurrence  in  the  inguinal  lymphatic  glands.  To  our 
surprise,  none  of  these  patients  has  died  as  a  result  of  a  recurrence.  The 
first  patient  lived  for  three  years  and  died  of  pneumonia.  The  second  lived 
for  a  period  of  six  years  without  recurrence  and  died  of  an  intercurrent 
disease.  The  third  is  alive  after  eleven  years ;  the  fourth  we  have  lost  sight 
of ;  the  fifth  is  well  after  five  years,  and  the  sixth  is  too  recent  to  be  of  any 
importance  in  this  consideration,  the  operation  having  been  performed  not 
much  over  one  year  ago,  but  he,  also,  is  free  from  recurrence.  In  all  of 
these  the  operation  was  done  with  the  greatest  thoroughness,  although  each 
case  at  the  time  of  the  operation  seemed  hopeless,  judging  from  the  experi- 
ence with  carcinoma  in  other  regions  of  the  body  after  the  lymphatic  glands 
have  been  involved.  In  all  of  these  we  employed  the  X-ray  in  the  after- 
treatment  with  the  exception  of  the  first  case. 

HYPOSPADIAS. 

This  deformity  is  so  common  that  it  seems  proper  to  describe  a  simple 
method  for  its  relief,  especially  as  the  presence  of  the  defect  seems  to  give 
rise  to  much  mental  suffering  on  the  part  of  the  parents  of  the  afflicted 
child. 

The  urethra  may  open  just  at  the  beginning  of  the  glans  and  then 
the  operation  to  be  employed  is  exceedingly  simple.  It  was  primarily  de- 
scribed by  Carl  Beck. 

An  incision  is  made  through  the  skin  in  the  median  line  from  its  open- 
ing to  a  point  from  one-third  to  one-half  the  distance  to  the  scrotum.  Skin 
flaps  are  then  dissected  to  either  side,  as  shown  in  Plate  CXXI,  Fig.  i.  The 
urethra  is  then  dissected  perfectly  free  this  entire  distance  back,  great  care 


72O  SURGERY    OF    THE    GENITOURINARY    TRACT 

being  taken  not  to  injure  its  delicate  wall  at  any  time.  The  glans  is  then 
transfixed  in  the  direction  of  the  urethra  by  means  of  a  very  sharp  trocar 
three  millimeters  in  diameter.  Caution  should  be  taken  to  place  this  opening 
two  or  three  millimeters  above  the  small  dimple  in  the  center  of  the  glans, 
which  marks  the  point  at  which  the  meatus  was  normally  intended,  because 
if  this  is  not  done  the  or.gan  will  curve  downward  and  there  will  still  exist 
an  uncomfortable  deformity. 

A  pair  of  fine  hemostatic  forceps  is  then  passed  through  the  canal  which 
has  been  made  in  the  glans  in  this  manner  and  the  urethra  is  drawn  through 
the  opening  in  the  manner  shown  in  Plate  CXXI,  Fig.  I.  It  is  then  carefully 
sutured  in  place  with  two  rows  of  catgut  or  fine  silk  sutures.  The  lateral 
skin  flaps  are  then  united  as  shown  in  Plate  CXXI,  Fig.  n.  In  this  manner 
the  deformity  can  be  almost  completely  corrected  and  the  functional  con- 
ditions are  very  greatly  improved.  The  tissues  in  this  region  are  so  elastic 
that  they  readily  accommodate  themselves  to  these  new  relations,  and  the 
results  of  this  operation  are  very  satisfactory. 

In  case  the  urethra  opens  far  back  from  the  glans,  another  method 
is  indicated  which  will  supply  a  new  urethra  artificially  formed  out  of  the 
tissues  of  the  prepuce,  as  shown  in  Fig.  i  and  n,  Plate  CXXII." 

The  prepuce  in  cases  of  hypospadias  is  usually  redundant  and  situated 
on  the  dorsal  surface,  overhanging  the  glans  like  a  hood.  The  skin  of  the 
penis  is  noted  for  its  thinness,  having  no  adipose  tissue,  also  for  its  loose- 
ness of  attachment  and  elasticity.  Where  it  is  folded  upon  itself  at  its 
cervical  attachment  its  character  very  nearly  resembles  mucous  membrane. 
The  prepuce  is  extended  as  for  circumcision,  and  two  incisions  are 
made,  about  one  inch  apart,  extending  from  its  free  border  to  its  attach- 
ment at  the  penile  cervix ;  the  prepuce  is  unfolded,  forming  a  loop  of  thin 
skin  about  six  centimeters  in  length.  Should  this  not  be  considered  suffi- 
cient to  reach  from  its  attachment  to  the  hypospadiac  opening,  the  two  in- 
cisions are  extended  back  along  the  dorsum  of  the  penis  until  sufficient 
tissue  is  obtained,  when  the  two  incisions  are  connected  by  a  transverse 
one,  and  the  flap  of  the  skin  lifted,  but  left  attached  to  the  cervix  by  the 
inner  surface.  Several  sutures  now  close  the  lateral  integument  of  the 
penis  over  the  denuded  area.  (Plate  CXXII,  Fig.  I.) 

The  peduculated  flap  of  prepuce  is  constructed  into  a  tube  with  its 
skin  or  outer  surface  inside,  by  means  of  a  number  of  catgut  sutures.  The 
penis  is  tunneled  by  means  of  a  narrow  bistoury  or  medium  trocar  and 
cannula,  through  the  glans,  above  its  groove,  along  the  penis  to  a  point  be- 
neath the  hypospadiac  opening,  when  it  is  made  to  emerge  at  one  side  of, 
but  close  to,  the  urethra ;  the  tube  of  prepuce  is  drawn  through  the  tunnel 
and  sutured  where  it  enters  the  glans  and  also  where  it  emerges.  (Plate 
CXXII,  Fig.  ii.)  At  the  end  of  ten  days  the  flap  of  pedicle  is  cut  through 
close  to  the  new  meatus.  The  second  operation,  made  at  a  later  period, 
consists  of  a  perineal  opening  into  the  urethra  and  insertion  of  a  Jacobs' 
self-retaining  female  catheter ;  this  is  the  least  irritating  and  can  be  left  as 
long  as  needed,  usually  from  five  to  eight  days.  An  incision  at  the  termina- 
tion of  the  two  urethras  now  admits  of  accurate  coaptation  by  sutures,  or 
the  normal  urethra  may  be  mobilized  to  a  sufficient  extent  to  admit  of  its 
insertion  into  the  caliber  of  the  new  urethra,  where  it  is  held  by  sutures 
and  the  external  parts  closed  over  this.  Occasionally  a  little  urine  escapes 
into  the  urethra  and  the  entire  canal  is  best  drained  by  passing  several  silk- 
worm strands  of  horsehair  through  the  urethra  and  out  alongside  the  ca- 


SURGERY    OF    THE    GENITOURINARY    TRACT  721 

theter  in  the  perineal  opening.  When  union  of  the  canals  is  complete  the 
drains  are  removed  and  the  perineal  drainage  will  usually  close  itself  in  a 
few  days.  Horsehair  and  fine  catgut  have  proved  the  best  suture  material 
for  this  form  of  plastic  work. 

The  advantages  of  this  combined  operation  are: 

Advantages. 

1.  A  urethral  tube  of  thin,  elastic  skin,  nearly  approaching  mucous 
membrane,  yet  having  no  hair  surface  to  occasion  later  complications. 

In  performing  this  operation  it  is  especially  important  to  bear  in  mind 
the  following  point :  A  sufficiently  large  flap  must  be  made  to  provide  a 
urethra  that  will  reach  without  tension. 

2.  The  trocar  opening  through  the  body  of  the  penis  must  be  very 
large,  in  fact  so  large  that  the  circulation  in  the  new  urethra  will  not  be 
interfered  with  after  the  organ  becomes  edematous. 

3.  A  perineal  drain  for  the  bladder,  with  a  self-retaining  Jacobs'  fe- 
male catheter,  must  be  employed. 

4.  A  silkworm  drain  for  the  urethra  should  always  be  inserted. 

This  method  is  capable  of  application  to  the  worst  types  of  hypospadiac 
cases. 

If  there  is  a  marked  groove  in  the  penis,  indicating  the  fact  that  the 
lack  of  closure  of  the  canal  depended  upon  a  very  small  defect,  a  method 
which  was  most  perfectly  described  and  illustrated  by  C.  H.  Mayo  will  be 
found  most  useful. 

Methods  of  C.  H.  Mayo. 

Plates  CXXIII  and  CXXIV  (a)  show  the  original  incisions,  which  are 
not  nearly  as  far  apart  near  the  glans  penis  as  they  must  be  in  order  to  secure 
an  ample  urethra.  At  (b)  the  lower  flap  is  dissected  up,  which  is  presently 
to  be  utilized  for  covering  the  urethra  formed  of  the  upper  portion.  At 
(c)  this  urethra  has  been  formed  by  suturing  the  free  edges  with  fine  cat- 
gut. At  (d)  the  lower  flap  has  been  sutured  upward,  twisted  180  degrees 
upon  its  pedicle  and  its  edges  have  been  sutured  to  the  edges  of  the  wound 
from  which  the  tissue  was  cut  to  form  the  urethral  canal. 

CXXV  and  CXXVI  illustrate  another  equally  ingenious  method  which 
has  the  advantage  of  not  using  long  flaps,  but  the  disadvantage  of  subjecting 
the  tissues  to  a  certain  degree  of  tension,  although  this  may  be  relieved  in  a 
measure  by  making  a  longitudinal  incision  through  the  skin  on  the  dorsal 
surface  of  the  penis  from  the  glans  to  the  pubis.  At  (e)  the  flap  is  being 
cut  and  elevated  to  produce  the  new  urethra;  at  (f)  this  is  further  devel- 
oped, showing  also  the  perforation  of  the  glans;  at  (g)  the  new  urethra 
has  been  covered  by  the  lateral  flaps  and  in  order  to  relieve  the  tension 
from  these  a  row  of  mattress  sutures  has  been  applied,  because  without 
these  the  line  of  suture  invariably  opens,  (rf)  represents  a  cross-section 
of  the  penis  after  all  sutures  have  been  applied. 

The  mattress  sutures  are  tied  rather  loosely  over  a  fine  rubber  drain- 
age tube  at  each  edge  in  order  to  allow  for  the  edema  which  always  appears. 

Plates  CXXYIT  and  CXXYTTI  illustrate  still  another  method  applicable 
to  cases  of  very  slight  degree,  as  shown  at  (i).  where  the  urethra  reaches  to 
the  base  of  the  glans.  or  in  cases  as  shown  at  (j)  in  which  the  urethra  can  be 
mobilized  and  brought  forward,  the  glans  being  perforated  so  that  the  end 
of  the  urethra  will  open  at  the  proper  point.  In  this  operation  it  is  again 


722  SURGERY    OF    THE    GENITOURINARY    TRACT 

important  to  make  ample  flaps  so  short  there  will  be  no  tension.  At  (k) 
this  operation  is  shown  as  completed. 

Another  ingenious  plan  is  represented  in  Plate  CXXVIII  (1),  in  which  a 
flap  has  been  cut  in  the  scrotum  just  sufficient  to  make  the  inferior  lining 
of  the  urethra.  This  is  sutured  into  two  incisions,  forming-  a  flap  which 
will  make  the  anterior  half  of  the  urethral  lining.  After  perfect  union 
has  been  accomplished  this  flap  is  dissected  up,  leaving  the  urethra  closed. 
The  new  surface  formed  may  be  covered  with  a  long  narrow  skin  graft, 
or  it  may  be  permitted  to  become  covered  with  epithelium  from  the  edges. 

The  objection  to  this  method  lies  in  the  fact  that  occasionally  a  few 
hairs  will  grow  in  the  part  of  the  urethra  formed  from  the  flap  taken  from 
the  scrotum,  and  the  earthy  phosphates  contained  in  the  urine  are  likely  to 
collect  on  these  hairs. 

In  many  cases  the  penis  is  curved  downward  because  of  the  shortness 
of  the  skin  and  fascia  on  the  inferior  surface.  To  overcome  this  deformity 
a  transverse  incision  may  be  made  through  all  of  the  tissues  that  bind  the 
organ  and  then  the  wound  can  be  spread  lengthwise,  as  at  (in)  Plate  CXXIX. 

Almost  innumerable  methods  have  been  practised,  as  suggested  by  the 
conditions  present  in  the  particular  case  under  consideration:  at  (o)  Plate 
CXXX  is  represented  an  ingenious  plan  of  arrangement  which  prevents  the 
incision  in  the  urethra,  and  that  in  the  skin,  from  coming  opposite  each  other. 

In  all  of  these  operations  it  is  well  to  make  a  perineal  urethrotomy 
through  which  a  retention  catheter  is  inserted,  which  is  kept  in  place  until 
the  wound  has  healed.  Neglecting  to  take  this  precaution  usually,  or  at 
least  frequently,  results  in  failure. 

While  the  retention  catheter  is  in  place  it  is  important  to  give  a  small 
amount  of  aromatic  sulphuric  acid,  or  some  other  mineral  acid,  in  distilled 
water  every  two  or  three  hours  to  prevent  the  accumulation  of  earthy  phos- 
phates in  the  catheter.  The  close  must,  of  course,  be  regulated  according 
to  the  age  of  the  patient. 

Another  precaution  which  it  is  important  to  take  into  account  in  all 
of  these  operations  is  the  fact  that  in  many  cases  a  satisfactory  ultimate  re- 
sult can  be  obtained  much  sooner  if  the  operation  is  carried  out  in  a  num- 
ber of  stages,  and  if  these  stages  are  not  hurried,  as  one  frequently  loses 
much  that  has  been  gained  by  a  little  too  much  haste.  One  must  also  bear 
in  mind  the  fact  that  considerable  edema  is  to  be  expected  and  that  conse- 
quently due  allowance  must  be  made  for  this  in  order  to  prevent  the  occur- 
rence of  pressure  necrosis,  which  would  otherwise  result  from  the  addi- 
tional tension  caused  by  the  edema. 

Again  the  principle  that  to  obtain  satisfactory  results  from  opera- 
tions for  the  correction  of  deformities  we  must  overcorrect  them,  is  illus- 
trated strikingly  in  this  operation. 

VARICOCELE. 

This  condition  is  found  mostly  in  boys  above  the  age  of  sixteen. 
Classes. 

There  are  three  distinct  classes  under  which  all  patients  may  be  dis- 
tributed from  a  clinical  standpoint.  In  the  first  there  are  no  symptoms ;  the 
patient  discovers  the  deformity  by  accident  or  it  is  recognized  by  his  physi- 
cian incidentally.  In  the  second  class  the  patient  has  suffered  severely  from 


PLATE  CXXXI. 

VARICOCELE  OPERATION. 

a  vas  deferens ;  b  varicose  veins  the  two  stumps  being  sutured  together  with 
catgut  suture  <-o  elevate  the  testicle  in  left  side  of  the  scrotum. 


SURGERY    OF    THE    GENITOURINARY    TRACT  725 

a  dragging  pain  in  the  left  side  of  the  scrotum,  extending  into  the  groin  and 
frequently  into  the  back.  This  pain  is  increased  when  the  patient  is  com- 
pelled to  stand  at  his  work  or  lift  heavy  weights.  It  is  also  much  more 
severe  when  he  is  tired,  especially  during  warm  weather.  This  is  a  marked 
feature  of  varicocele,  that  the  number  of  cases  regularly  increases  in  our 
hospital  service  with  the  approach  of  warm  weather  and  decreases  in  win- 
ter. In  the  third  class  the  patient  is  neurasthenic  and  has  attributed  many 
forms  of  mental  and  physical  suffering  to  the  varicocele.  He  may  suffer 
physically  in  the  same  manner  as  the  patient  in  the  second  class,  but  the 
prominent  symptoms  are  those  of  neurasthenia. 

Diagnosis. 

There  is  a  marked  difference  upon  palpation  in  the  right  and  left  half 
of  the  scrotum.  On  the  right  side  can  be  distinguished  a  hard,  cord-like 
structure — the  vas  deferens —  extending  the  entire  distance  of  the  scrotum, 
with  the  testicle  located  at  its  lower  end.  On  the  left  side  these  structures 
are  almost  concealed  by  a  large  accumulation  of  elastic,  worm-like  structures 
coiled  upon  themselves,  giving  rise  to  the  sensation  which  has  been  com- 
pared to  the  manipulation  of  a  number  of  angleworms.  This  is  due  to  the 
great  dilatation  of  the  spermatic  veins,  which  are  in  a  varicose  condition. 

If  the  patient  is  placed  in  the  recumbent  position  the  veins  become 
empty  and  can  no  longer  be  felt  unless  the  affection  has  existed  for  a  long 
time,  in  which  case  the  walls  of  the  veins  themselves  will  have  become 
thickened  in  the  natural  tendency  of  compensation,  and  then  the  change 
in  the  fullness  of  the  vessels  will  not  so  completely  alter  the  impression 
upon  palpation. 

Very  rarely  the  condition  is  present  upon  both  sides,  and  still  more 
rarely  upon  the  right  side  alone,  because  the  anatomical  difference  of  the 
two  sides  favors  the  formation  of  varicocele  upon  the  left. 

The  malady  is  so  characteristic  that  it  is  not  likely  to  ever  be  con- 
founded with  any  other. 

Indications  for  Operation. 

In  the  first  class  the  operation  is  plainly  not  indicated  as  in  itself  the 
condition  is  harmless  so  long  as  it  gives  rise  to  neither  pain  nor  discomfort. 
It  neither  causes  any  other  pathological  state  nor  does  it  predispose  to  any; 
hence  there  can  be  no  good  reason  for  surgical  procedure.  In  these  cases  it 
may  be  proper  to  advise  the  wearing  of  a  well-fitting  suspensory  bandage, 
which  will  tend  to  prevent  the  further  dilatation  of  the  veins. 

In  the  second  class  surgical  treatment  is  strongly  indicated,  because,  if 
properly  executed,  it  will  result  in  permanent  relief  in  almost  every  case.  It 
can  be  performed  with  safety  to  the  patient,  and  it  will  disable  him  from 
work  only  for  a  very  short  time. 

In  the  third  class  it  is  necessary  to  determine  whether  there  is  any 
possibility  of  casual  relation  between  the  varicocele  and  the  neurasthenia. 
If  such  a  relation  can  be  established  the  operation  is  plainly  indicated.  If 
there  is  as  plainly  no  relation  between  the  two,  then  the  operation  is  not 
called  for  unless  there  seems  to  be  reason  to  suppose  that  the  presence  of 
the  deformity  causes  undue  anxiety  in  the  mind  of  the  patient,  which  in  turn 
causes  or  increases  his  neurasthenia.  In  such  event  the  removal  of  the 
deformity  might  remove  at  least  one  cause  of  the  neurasthenia. 

If  there  is  doubt  in  these  cases  it  seems  but  fair  that  the  patient  be 


726  SURGERY    OF    THE    GENITOURINARY    TRACT 

given  the  benefit  thereof,  and  that  surgical  relief  of  the  pathological  condi- 
tion be  employed. 

Technique. 

An  incision  three  to  four  centimeters  in  length  is  made  directly  over 
the  spermatic  cord  downward  from  a  point  just  below  the  external  abdom- 
inal ring.  The  blood  vessels  which  appear  in  the  incision  are  either  caught 
at  once  between  two  pairs  of  hemostatic  forceps  and  then  cut,  or  the  in- 
cision is  made  directly  down  to  the  tissues  of  the  spermatic  cord  and  the 
bleeding  points  thus  caught  with  hemostatic  forceps. 

It  is  important  that  throughout  this  operation  all  bleeding  be  carefully 
controlled,  in  order  to  prevent  infiltration  of  the  tissues  with  blood  or  the 
formation  of  a  hematoma,  for  both  of  these  states  are  exceedingly  annoying, 
not  so  much  on  account  of  their  inherent  importance  as  because  of  the 
anxiety  they  produce  in  the  patient. 

The  cord  is  then  brought  up  into  the  wound  and  the  vas  deferens,  with 
a  few  of  the  accompanying  small  arteries  and  veins,  isolated.  This  leaves 
the  great  mass  of  varicose  veins  in  a  separate  bunch.  After  carefully  car- 
rying this  separation  from  the  external  abdominal  ring  to  a  point  half  an 
inch  from  the  testicle,  the  mass  of  veins  is  transfixed  above  and  below  with 
a  double  cat-gut  ligature  and  tied  in  halves.  The  intervening  portion  is  then 
cut  away,  caution  being  taken  to  leave  a  sufficient  amount  of  tissue  beyond 
the  ligatures  to  prevent  slipping.  The  two  stumps  are  then  united  with  cat- 
gut sutures  to  prevent  the  dragging  down  of  the  testicle,  with  its  subsequent 
discomfort. 

There  is  some  danger  of  shortening  the  cord  too  much  so  that  the 
testicle  will  be  drawn  up  close  to  the  external  abdominal  ring.  This  does 
not  give  rise  to  any  pain,  but  the  deformity  may  cause  an  increase  in  the 
neurasthenic  condition  of  the  patient.  If  possible  the  testicle  on  the  op- 
erated side  should  hang  only  a  little  higher  than  the  opposite  one.  It  is 
quite  important  to  have  the  result  both  cosmetically  and  anatomically  as 
nearly  perfect  as  possible. 

The  deep  fascia  is  then  sutured  with  fine  cat-gut,  and  later  the  skin. 
It  seems  best  to  suture  the  fascia  separately  in  order  to  prevent  the  infection 
of  the  deep  tissues  from  the  skin.  An  ordinary  gauze  dressing  is  applied 
to  the  wound  and  held  in  place  with  a  suspensory  bandage.  The  wound 
usually  heals  within  a  week,  and  the  patient  is  able  to  perform  ordinary  work 
in  two  weeks.  This  is  a  very  satisfactory  operation  as  a  rule,  because  it  is 
thoroughly  appreciated  by  the  patient. 

If  one  approaches  the  testicle  too  closely  in  the  operation  the  resulting 
irritation  is  likely  to  cause  the  formation  of  a  hydrocele.  In  order  to  pre- 
vent this  in  any  case  in  which  there  seems  such  a  likelihood,  it  is  best  to 
split  the  tunica  vaginalis,  evert  it  and  suture  it  in  the  everted  position  before 
replacing  the  testicle  in  the  scrotum.  In  cases  in  which  this  has  not  been 
clone,  and  in  which  a  hydrocele  does  occur  after  a  varicocele  operation,  the 
injection  method  for  the  treatment  of  hydrocele  (to  be  described  directly), 
usually  gives  immediate  and  permanent  relief. 

HYDROCELE. 

This  may  affect  either  the  tunica  vaginalis  of  the  testicle,  or  of  the  sper- 
matic cord,  or  both. 


Hvdrocele. 


PLATE  CXXXIT. 

Encysted  hydrocele  of  the  cord  extending  upwards  and  forming  a  large  tumor  in 
the  abdomen,     a.  Upper  limit  of  abdominal  Tumor. 


Fig.  25. 
The  Wyllys  Andrews  Method. 


SURGERY    OF    THE    GENITOURINARY     TRACT  731 

The  change  is  usually  attributed  to  an  acute  trauma,  or  there  may  have 
existed  an  orchitis  due  to  a  specific  urethritis.  The  physician  is  usually  not 
consulted  until  the  tumor  has  attained  so  great  a  size  that  its  weight  gives 
rise  to  discomfort,  and  it  may  annoy  the  patient  on  account  of  the  deformity, 
or  it  may  even  interfere  with  locomotion.  It  is  usually,  but  not  always,  uni- 
lateral. 

Diagnosis. 

Aside  from  the  rare  occurrence  of  sarcoma  so  soft  in  structure  as  to 
simulate  fluctuation,  the  only  condition  with  which  hydrocele  can  be  con- 
founded is  scrotal  hernia.  This  is  true  especially  in  children  in  whom  the 
contents  of  a  hernia  frequently  give  the  same  impression  on  palpation  as  the 
liquid  contained  in  a  hydrocele.  This  is  especially  true  in  hydrocele  of  the 
cord,  which  is  located  in  the  lower  end  of  the  inguinal  canal  and  which  can 
frequently  be  reduced  through  the  inguinal  canal  into  the  peritoneal  cavity. 
There  is,  however,  this  difference,  viz.,  hydrocele  will  always  reduce  as  a 
solid  mass,  only  to  reappear  in  a  few  moments  without  regard  to  the  form 
of  truss  that  may  be  applied,  while  hernia  will  give  the  sensation  of  being 
composed  of  loose  substance,  and  it  will  remain  reduced  if  properly  sup- 
ported by  a  truss. 

In  hydrocele  of  the  tunica  vaginalis  the  light  test  is  the  most  reliable. 
A  small  tube  is  applied  to  the  side  of  the  scrotum,  then  a  light  is  placed  upon 
the  opposite  side.  If  the  light  is  seen  through  the  tube  it  is  an  indication  that 
the  mass  is  composed  of  a  sac  containing  transparent  fluid.  However,  it 
sometimes  happens  that  the  hydrocele  is  so  thick-walled  in  old  patients  that 
no  light  will  penetrate.  Occasionally  the  fluid  may  not  be  transparent,  be- 
ing discolored  by  blood  pigments,  and  then  the  light  test  may  be  misleading. 
A  very  simple  test  consists  in  grasping  the  scrotum,  directly  above  the  mass, 
between  the  finger  and  thumb.  If  the  tissues  of  the  cord  can  be  plainly  dis- 
tinguished the  case  is  one  of  hydrocele;  if  not,  it  is  a  hernia. 

Abscesses  may  be  distinguished  by  the  evidences  of  inflammation ; 
edema  of  the  scrotum,  because  of  edema  elsewhere  in  the  body.  Tumors 
of  the  testicle  are  usually  hard,  and  do  not  fluctuate. 

Occasionally  in  old  patients  in  whom  the  hydrocele  has  existed  for  a 
long  time,  especially  if  it  has  been  frequently  tapped,  the  walls  of  the  cyst 
undergo  calcareous  degeneration,  giving  the  impression  of  a  hard  tumor. 
This  has  repeatedly  been  mistaken  for  sarcoma  or  enchondroma,  a  mistake 
which  is  quite  unfortunate,  because  it  is  usually  not  discovered  until  after 
the  organ  has  been  removed. 

Technique  in  Children. 

In  children  simple  tapping  will  suffice  to  bring  about  a  permanent  cure. 
This  may  be  repeated  a  few  times  if  necessary,  and  if  not  permanently  suc- 
cessful it  should  be  followed  by  the  injection  into  the  sac,  after  the  latter 
has  been  very  carefully  emptied,  of  a  few  drops  of  ninety-five  per  cent,  car- 
bolic acid.  The  cannula  of  the  trocar  should  be  closed  and  left  in  place 
while  the  carbolic  acid  is  distributed  over  the  entire  surface  by  carefully 
massaging  the  scrotum.  After  a  few  minutes  the  cannula  should  be 
opened,  and  whatever  fluid  may  have  again  accumulated,  together  with  the 
carbolic  acid,  should  be  drawn  off.  In  small  children  five  drops  of  a  thirty 
per  cent,  solution  of  carbolic  acid  in  glycerine  will  suffice,  if  the  sac  has 
been  carefully  emptied  before  this  fluid  is  injected.  It  does  not  matter  if 


732  SURGERY    OF    THE    GENITOURINARY    TRACT 

all  of  this  fluid  remains  in  the  sac,  as  the  amount  is  not  sufficient  to  cause 
symptoms  of  poisoning  from  absorption. 

During  the  entire  manipulation  the  external  abdominal  ring  should  be 
compressed,  in  order  to  prevent  the  introduction  into  the  peritoneal  cavity  of 
any  portion  of  the  carbolic  acid,  in  case  the  upper  end  of  the  tunica  vag- 
inalis  has  not  yet  become  entirely  closed. 

In  hydrocele  of  the  cord  in  children  tapping  alone  almost  always  suf- 
fices. If  this  is  not  the  case,  it  is  well  to  make  a  longitudinal  incision, 
opening  the  hydrocele  and  tamponing  the  cavity  with  iodoform  gauze.  After 
a  few  days  the  gauze  may  be  removed  and  the  wound  will  heal  completely 
in  a  short  time.  It  does  not  matter  that  the  inguinal  canal  is  thus  left  wide 
open  after  the  hydrocele  of  the  cord  which  closed  it  has  been  emptied  and 
can  consequently  no  longer  act  as  a  plug.  During  the  short  period  that  the 
child  will  be  compelled  to  remain  in  the  recumbent  position  the  canal  will 
contract  sufficiently  to  prevent  the  protrusion  of  a  hernia. 

Technique  in  Adults. 

If  the  patient  can  conveniently  abandon  his  work  for  one  to  two 
weeks,  it  is  usually  best  to  advise  the  operation  for  radical  cure,  to  be  de- 
scribed presently.  If  he  cannot  leave  his  work  and  desires  only  temporary 
relief,  tapping  will  accomplish  this.  If  he  cannot  remain  away  from  his 
work,  but  still  desires  to  obtain  some  hope  of  a  permanent  cure,  without  a 
certainty,  it  may  be  well  to  make  use  of  the  ninety-five  per  cent,  carbolic 
acid,  just  mentioned,  with  a  change  in  the  quantity  to  be  employed.  After 
aspirating  the  fluid,  from  one  to  two  drachms  of  ninety-five  per  cent,  car- 
bolic acid  is  injected  and  forced  into  contact  with  every  portion  of  the  lining 
of  the  sac  by  massage.  The  acid  should  be  left  in  contact  with  the  surface 
for  at  least  five  minutes,  then  it  should  be  forced  out  through  the  cannula, 
which,  of  course,  has  in  the  meantime  been  kept  closed.  The  patient  should 
then  be  put  to  bed  for  a  few  hours,  after  which  he  may  resume  his  occupa- 
tion. In  our  own  practice  we  have  frequently  applied  this  treatment  on 
Saturday  evening,  and  the  patient  has  always  been  able  to  resume  work  with 
perfect  comfort  on  Monday  morning. 

In  about  one-half  of  all  the  cases  this  method  will  result  in  a  perma- 
nent cure,  and  it  is  worth  while  to  explain  to  each  patient  coming  for  treat- 
ment the  first  time,  that  in  about  one-half  the  cases  this  simple  method  will 
accomplish  everything  he  may  desire.  The  method  has  the  further  ad- 
vantage of  being  painless.  Recently  we  have  followed  the  plan  practised  by 
Coley  of  completely  aspirating  the  fluid  contained  in  the  hydrocele  and  then 
injecting  five  drops  of  a  ninety-five  per  cent,  solution  of  carbolic  acid,  or 
fifteen  drops  of  a  thirty  per  cent,  solution  in  glycerine,  and  leaving  this 
in  the  sac.  The  proportion  of  cures  seems  to  be  about  equal  to  that  just 
described. 

Radical  Operation. 

An  incision,  one  and  one-half  inches  in  length,  is  made  over  the  ante- 
rior surface  of  the  side  of  the  scrotum  involved,  directly  down  through 
the  tunica  vaginalis,  which  will  permit  the  fluid  to  escape.  The  inner  sur- 
face of  the  sac  and  the  surface  of  the  testicle  are  carefully  inspected  in  or- 
der to  detect  any  tubercles  which  might  account  for  the  accumulation  of 
fluid.  If  present  they  are  carefully  removed,  preferably  with  the  knife  of 
an  electro-cautery.  If  none  are  found  the  tunica  vaginalis  is  everted  over 
the  testicle  and  held  by  a  few  stitches  of  cat-gut ;  then  the  testicle,  together 


SURGERY    OF    THE    GENITOURINARY    TRACT  733 

with  its  everted  tunica  vaginalis,  is  replaced  in  the  scrotum.  Great  care  is 
exercised  to  secure  absolutely  perfect  hemostasis  so  as  to  prevent  any  ac- 
cumulation of  blood  in  the  scrotum  after  the  operation.  The  deep  fascia  is 
first  sutured  with  cat-gut  and  then  the  skin  is  united.  An  ordinary  dressing 
is  applied  and  held  in  place  by  a  suspensory  bandage. 

It  is  very  important  to  inspect  the  testicle  carefully  in  order  to  dis- 
cover any  small  cysts  which  may  be  present  on  the  surface,  either  because 
of  the  adhesion  of  a  portion  of  the  tunica  vaginalis,  or  of  accumulation  of 
serum  underneath  the  portion  of  this  structure  covering  the  testicle.  In 
either  event  the  anterior  layer  of  tunica  vaginalis  is  cut  away  entirely  in 
order  to  exclude  the  possibility  of  a  recurrence. 

The  wound  heals  in  a  few  days,  and  in  a  week  the  patient  is  able  to 
follow  his  usual  labor.  The  operation  is  so  simple,  safe  and  satisfactory 
in  its  results  that  it  seems  foolish  for  one  to  carry  a  hydrocele  about  for 
years  and  go  through  the  annoyance  of  repeated  tappings  when  he  might 
in  a  few  days  obtain  permanent  and  perfect  relief. 

CYSTOTOMY. 

During  the  past  few  years  it  has  become  an  almost  universal  practice 
to  open  the  bladder  through  a  suprapubic  incision  for  the  removal  of  stones 
and  foreign  growths,  and  for  permanent  drainage  of  the  bladder  from  any 
cause.  The  operation  in  itself  is  relatively  simple. 

Preparatory  Treatment. 

Before  undertaking  any  operation  upon  the  bladder  it  is  desirable  that 
the  urine  should  be  as  nearly  aseptic  as  possible.  Measures  should  be 
taken  to  make  the  urine  as  nearly  normal  as  the  conditions  of  the  patient 
will  permit.  That  affection  for  which  the  operation  is  required  usually 
predisposes  to  an  abnormal  state  of  the  urine,  and  frequently  not  only  the 
bladder,  but  also  the  kidneys  are  diseased.  If  the  urine  contains  septic 
material  this  may  be  changed  by  dilution,  the  patient  being  given  large 
quantities  of  distilled  water,  or,  if  this  is  not  agreeable,  one  of  the  various 
mineral  waters  in  large  quantities.  Such  course  will  reduce  the  septic  char- 
acter of  the  urine  to  a  great  extent.  If  the  urethra  is  permeable  to  the  pas- 
sage of  a  catheter,  irrigation  of  the  bladder  with  a  mild,  non-irritating  an- 
tiseptic solution,  such  as  boric  acid;  i:  1,000  solution  of  permanganate  of 
potash ;  1 :2,ooo  solution  of  nitrate  of  silver ;  a  saturated  solution  of  ace- 
tate of  aluminum ;  or  a  solution  of  any  one  of  a  number  of  recently 
produced  silver  salts,  may  be  used.  These  silver  salts  have  the  advantage 
of  not  being  precipitated  by  contact  with  urine.  These  solutions  may  be 
used  in  from  one  to  ten  per  cent,  strength,  and  from  one  to  two  ounces 
may  be  safely  left  in  the  bladder  after  conclusion  of  the  irrigation.  If  a  so- 
lution of  nitrate  of  silver  is  used  the  bladder  should  first  be  irrigated  re- 
peatedly with  distilled  or  boiled  water,  as  otherwise  all  of  the  silver  will 
at  once  be  made  useless  by  being  precipitated  in  the  form  of  silver  chloride. 
Adding  an  ounce  of  strong  alcohol  to  a  pint  of  saturated  solution  of  boric 
acid  makes  one  of  the  best  solutions  for  irrigation. 

Care  should  be  taken  not  to  irritate  the  bladder  with  any  of  these  so- 
lutions. If  it  is  found  that  one  irritates  more  than  the  other  it  should  be 
avoided.  The  bladder  should  be  filled  moderately  full  and  then  the  fluid 
permitted  to  escape,  or  the  bladder  may  be  irrigated  with  a  constant  stream 


734  SURGERY    OF    THE    GENITOURINARY    TRACT 

through  a  double  catheter,  one  tube  serving  the  purpose  of  introducing 
the  fluid,  the  other  of  emptying  the  bladder.  A  repeated  examination  of 
the  urine  will  determine  whether  this  treatment  reduces  the  amount  of  septic 
material  regularly  found. 

There  are  a  number  of  antiseptics  that  may  be  given  internally  as 
urinary  disinfectants.  Of  these  five  grain  doses  of  boric  acid  given  with 
half  a  pint  of  distilled  water,  or  mineral  water,  every  three  hours;  the  same 
dose  of  salol,  or  of  urotropin ;  or  one-grain  doses  of  methylene-blue  given 
in  the  same  manner,  are  probably  the  most  useful.  There  is,  however,  this 
fact  to  remember,  that  urine  usually  is  most  septic  if  the  bladder  is  not 
at  any  time  completely  evacuated,  and  consequently  but  a  slight  amount 
of  benefit  is  to  be  expected  unless  the  residual  urine  is  removed  once  or 
twice,  or  oftener,  each  day,  and  the  bladder  carefully  irrigated. 

Just  before  the  operation  the  bladder  should  again  be  carefully  and 
repeatedly  irrigated  so  that  any  accumulation  of  septic  material  may  be 
thoroughly  washed  away,  and  any  remnants  that  cannot  be  so  \vashed  away 
may  be  thoroughly  diluted.  In  many  cases  the  bladder  contains  weakened 
points  and  consequently  great  care  should  be  used  in  this  final  irrigation, 
which  is  usually  performed  after  the  patient  has  been  anesthetized,  not  to 
fill  the  bladder  with  too  much  force  for  fear  of  causing  a  rupture  at  some 
frail  point.  After  this  irrigation  has  been  completed  the  bladder  should 
be  filled  moderately  either  with  air  or  water.  The  latter  may  be  injected 
through  a  catheter  by  means  of  an  ordinary  bulb  syringe,  not  more  than 
eight  ounces  being  introduced.  The  quantity  can  be  measured  by  the  size 
of  the  bulb  used.  In  case  air  is  used,  it  is  best  to  leave  the  catheter  in 
place  after  the  bladder  has  been  irrigated  and  to  attach  it  by  means  of  a 
glass  tube  to  a  rubber  bulb.  The  incision  is  then  made  through  all  the 
tissues  clown  to  fat  in  the  space  of  Retzius.  Then  the  bladder  is  pumped 
full  of  air  and  it  can  be  observed  as  it  expands  in  the  depths  of  the  wound. 

Many  surgeons  prefer  to  make  a  transverse  incision,  just  above  the 
pubic  bone,  down  to  the  aponeurosis  of  the  recti  muscles,  and  then  to  cut 
longitudinally  between  these  muscles.  We  have  made  this  incision,  as  well 
as  the  longitudinal  one  about  to  be  described,  and  have  found  both  equally 
satisfactory. 

The  field  of  operation  has,  of  course,  been  carefully  shaved  and  pre- 
pared ;  then  a  longitudinal  incision  is  made  in  the  median  line  directly  up- 
wards from  the  os  pubis,  a  distance  of  five  centimeters.  The  muscles  are 
separated  and  the  fat  above  the  pubis  and  front  of  the  bladder  exposed. 
This  contains  a  number  of  veins  of  considerable  size  which  usually  ex- 
tend transversely  or  obliquely  across  the  incision.  They  should  be  grasped 
with  hemostatic  forceps  on  either  side,  cut  and  ligated  at  once.  The  wound 
is  carried  through  the  fat  clown  to  the  wall  of  the  bladder.  In  making  this 
dissection  great  care  should  be  taken  not  to  extend  the  incision  too  high 
for  fear  of  entering  the  peritoneal  cavity.  This  is  not  likely  to  occur,  how- 
ever, if  the  bladder  is  filled  with  water  or  air  unless  the  viscus  is  pendu- 
lous and  displaced  backwards.  In  such  event  the  peritoneum  may  approach 
the  os  pubis  and  may  have  to  be  shoved  upwards  and  held  out  of  the  path 
of  operation  by  means  of  retractors.  A  suture  is  then  applied  to  the  wall 
of  the  bladder  in  the  upper  angle  of  the  wound  for  the  purpose  of  secur- 
ing it  against  separation  from  the  anterior  abdominal  wall.  Two  other 
stitches  are  applied  in  the  bladder  wall  with  curved  needles  one  centimeter 
to  each  side  of  the  median  line.  Forceps  should  be  applied  to  each  one  of 


SURGERY    OF    THE    GENITOURINARY    TRACT  735 

these  stitches,  and  the  bladder  wall  drawn  forward  gently.  A  longitudinal 
incision  is  then  made,  from  one  to  three  centimeters  in  length,  according  to 
the  object  of  the  cystotomy,  and  the  edges  of  the  wound  grasped  with 
fine-toothed  forceps  and  held  open  while  the  interior  of  the  bladder  is  being 
exposed.  As  soon  as  this  incision  is  made  the  fluid  (or  air)  contained  in 
the  bladder  will  escape  and  the  bladder  walls  begin  to  contract.  If  a  stone 
is  present  its  size  may  be  determined  and  the  incision  in  the  bladder  wall 
increased  if  necessary.  The  position  of  the  stone  is  determined  with  the 
finger,  and  it  is  grasped  by  means  of  stone  forceps  in  its  narrowest  diam- 
eter and  withdrawn  from  the  wound  in  the  bladder  with  the  gentlest  pos- 
sible motion.  The  interior  of  the  bladder  should  then  again  be  examined 
for  further  stones,  and  this  should  be  repeated  until  all  such  have  been 
removed.  If  a  tumor  is  present  an  assistant  should  introduce  two  or  three 
fingers  into  the  rectum  and  force  the  tumor  toward  the  wound  so  as  to  fa- 
cilitate its  examination  and  removal. 

The  method  of  removal  of  a  tumor  will  depend  largely  upon  its  size 
and  location,  and  must  be  determined  upon  general  principles  in  each  case. 

If  the  operation  has  been  undertaken  for  the  purpose  of  securing  per- 
manent drainage,  the  incision  should  be  made  as  near  the  os  pubis  as  pos- 
sible, and  be  only  just  large  enough  for  the  purpose  of  permitting  carefu\ 
digital  exploration.  Several  purse-string  sutures  should  then  be  applied  to 
prevent  leakage,  and  a  retention  catheter  introduced.  The  wound  should 
be  tamponed  around  this  retention  catheter  and  the  stitches  in  the  bladder 
wall  passed  through  the  edge  of  the  wound  and  tied  just  sufficiently  tight 
to  hold  the  anterior  wall  in  close  apposition  with  the  abdominal  wall.  A 
few  silkworm  gut  sutures  are  then  applied,  so  as  to  grasp  the  wound  on 
each  side,  and  to  take  a  small  bite  in  the  anterior  wall  of  the  bladder  above 
the  point  of  incision,  and  two  small  bites,  one  on  each  side  of  the  incision 
in  this  portion  of  the  bladder.  These  sutures  are  left  untied  until  the  first 
dressing,  which  occurs  a  few  days  after  the  operation,  when  the  gauze 
tampon  and  the  three  first  stitches  may  be  removed  and  the  silkworm  sutures 
may  be  tied,  leaving  only  a  space  open  through  which  the  drainage  tube 
passes.  If  the  bladder  has  been  in  a  septic  condition,  it  is  often  best  to 
pass  two  ordinary  rubber  drainage  tubes  one-half  a  centimeter  in  diameter, 
perforated  with  several  small  openings  in  the  end.  It  is  then  possible  to 
irrigate  the  bladder  by  permitting  the  fluid  to  flow  in  through  one  of  these 
tubes  and  out  of  the  other ;  and  in  case  one  or  the  other  becomes  occluded 
with  mucus  or  blood  the  free  one  will  suffice  to  drain. 

After-treatment. 

The  most  important  point  in  the  after-treatment  consists  in  giving  the 
patient  large  quantities  of  pure  water  to  drink.  If  the  patient  is  at  all 
shocked  by  the  operation  it  is  wise  to  give  him  a  saline  transfusion  at  once, 
or  to  give  him  an  enema  of  half  a  pint  of  normal  salt  solution  every  hour. 

It  is  well  to  give  the  patient  from  two  to  five  drops  of  dilute  aromatic 
sulphuric  acid  in  half  a  pint  of  distilled  water  every  hour  during  the  day, 
and  every  two  to  three  hours  during  the  night.  This  will  prevent  the  ac- 
cumulation of  earthy  phosphates  in  the  bladder  or  in  the  drainage  tubes. 

The  bladder  should  be  irrigated  with  a  saturated  solution  of  boric  acid 
from  two  to  six  times  a  clay,  according  to  the  character  of  the  urine.  If 
two  rubber  tubes  are  employed,  sufficiently  long  for  the  ends  to  project  into 
an  antiseptic  solution  in  a  bottle  tied  to  the  side  of  the  bed,  the  patient  will 


736  SURGERY    OF    THE    GENITOURINARY    TRACT 

usually  remain  perfectly  dry.  It  is  a  good  plan  to  insert  a  glass  tube  into 
the  end  of  the  rubber  tube,  so  that  its  weight  will  keep  it  from  becoming 
dislodged  from  the  bottle.  By  placing  a  Y-shaped  glass  tube  in  the  course 
of  the  tube  leading  from  the  bladder  to  the  bottle,  and  having  one  of  the 
short  legs  of  the  Y  attached  to  the  tube  coming  from  a  fountain  syringe 
suspended  from  a  point  higher  than  the  bed,  from  which  water  is  permit- 
ted to  drop  constantly,  the  rubber  tube  will  act  as  a  syphon  and  this  will 
serve  to  keep  the  bladder  empty  and  the  patient  dry.  If  the  rubber  tubes 
give  rise  to  pain  their  position  should  be  changed  occasionally.  The  bladder 
contracts  and  then  these  tubes  cause  irritation  by  pressing  upon  the  pos- 
terior wall  of  the  organ. 

If  the  operation  is  done  for  the  removal  of  a  stone  from  a  healthy  blad- 
der containing  nearly  normal  acid  urine  the  wound  in  the  bladder  may  be 
closed  by  a  double  row  of  catgut  sutures,  which  are  not  permitted  to  pen- 
etrate the  mucous  membrane,  however.  The  space  between  the  bladder  and 
the  abdominal  wall  should  always  be  drained  thoroughly  in  these  cases  for 
fear  of  extravasation  of  urine.  A  soft  rubber  retention  catheter  is  placed 
into  the  bladder  through  the  urethra  in  such  instances  and  carefully  fastened 
in  place,  so  as  to  keep  the  bladder  thoroughly  drained.  If  there  is  any  doubt 
about  the  septic  condition  of  the  bladder  it  does  not  seem  wise  to  close  the 
its  wall  completely. 

In  case  the  operation  is  performed  for  the  purpose  of  securing  per- 
manent drainage,  the  smaller  the  opening  in  the  bladder  the  better  will  the 
operation  serve  its  purpose.  In  these  cases  it  is  well  to  make  the  bladder 
opening  as  near  the  urethral  opening  as  possible.  If  a  permanent  drainage 
is  employed,  the  bladder  should  be  irrigated  at  least  once  a  day  with  some 
mild  antiseptic  solution,  and  it  is  advantageous  to  change  the  character  of 
this  solution  repeatedly,  because  an  occasional  change  wrill  increase  the  use- 
fulness of  any  of  the  various  antiseptic  solutions  which  have  been  men- 
tioned in  this  connection. 

TUMORS  OF  THE  BLADDER. 

In  the  removal  of  tumors  of  the  bladder  it  is  important  to  have  a  free 
view  of  the  field  of  operation.  This  is  secured  by  placing  the  patient  in 
the  exaggerated  Trendelenburg  position  and  making  a  median  abdominal 
section,  extending  from  the  pubis  to  the  umbilicus,  and  tamponing  all  of 
the  intestines  and  the  omentum  out  of  the  way  into  the  upper  portion  of 
the  abdominal  cavity.  The  bladder  has  of  course  been  previously  thor- 
ougely  irrigated,  as  described  above,  and  is  either  entirely  empty  or  mod- 
erately distended  \vith  air. 

It  is  usually  well  to  place  these  patients  on  a  diet  of  milk  and  egg  al- 
bumen for  a  fe\v  clays  before  the  operation  and  give  them  capsules  of  ten 
grains  of  gallic  acid  every  two  hours  for  one  or  two  days  before  the  op- 
eration, which  will  serve  to  reduce  the  hemorrhage  greatly.  This,  of  course, 
is  not  necessary  but  is  of  advantage. 

The  pelvic  cavity  behind  the  bladder  is  filled  with  a  gauze  tampon  to 
catch  any  slight  amount  of  urine  and  blood.  The  wall  of  the  bladder  is 
then  caught  with  fine-toothed  forceps  and  incised.  Whatever  urine  may 
be  present  is  carefully  sponged  away.  Then  the  tumor  is  excised  freely. 
If  it  includes  a  ureter  the  latter  is  picked  up  and  implanted  into  the  bladder 
wall  later,  according  to  the  method  already  described.  If  neither  the  ureter 


SURGERY    OF    THE    GENITOURINARY    TRACT  /3/ 

nor  the  osteum  of  one  or  both  ureters  is  involved,  then  the  bladder  wall  is 
sutured.  The  first  row  of  stitches  is  made  of  fine  chromic  catgut,  prefer- 
ably used  double.  This  is  applied  after  the  manner  of  the  Connell  suture 
in  intestinal  surgery,  which  has  been  described  and  illustrated  elsewhere 
herein.  A  second  row  of  sutures  is  passed  over  this  after  the  manner  of  the 
Lembert  suture  in  intestinal  surgery.  This  may  be  done  with  a  fine  ten-day 
catgut,  or  with  silk  or  linen.  It  is  not  necessary  to  apply  drainage,  either 
to  the  bladder  wound  or  the  cavity  of  the  bladder ;  a  retention  catheter  is 
likely  to  cause  more  harm  than  good. 

If  the  ureters  are  involved  to  an  extent  making  an  implantation  into 
the  bladder  impossible  the  case  is  usually  hopeless,  but  it  may  be  worth 
while  to  make  an  oblique  implantation  into  the  colon  according  to  the  method 
already  described. 

URETHROTOMY. 

In  urethral  strictures  which  cannot  comfortably  be  kept  open  by  means 
of  bougies  passed  regularly  by  the  physician,  or  in  this  condition  accom- 
panied by  a  constant  or  interrupted  discharge,  or  in  the  presence  of  pain,  or 
other  abnormal  conditions  which  can  be  attributed  to  a  stricture,  the  latter 
should  be  thoroughly  divided.  This  is  true  even  in  cases  in  which  annoy- 
ing nervous  symptoms  referable  to  strictures  persist  where  it  is  possible  to 
pass  a  sound  of  normal  size. 

These  patients  usually  give  the  history  of  one  or  more  attacks  of 
gonorrheal  urethritis,  followed  in  time  by  an  obstruction  to  the  flow  of 
urine,  which  may  be  only  slight  or  almost  complete.  During  the  entire  time 
there  may  have  been  a  certain  amount  of  urethral  discharge,  possibly  only 
a  drop  in  the  morning.  This  may  be  associated  with  an  irritable  bladder, 
which  refuses  to  retain  urine  for  the  normal  period  of  time.  There  may 
be  a  sensation  of  scalding  during  micturition. 

Diagnosis. 

The  urethra  should  be  thoroughly  irrigated  with  a  saturated  solution 
of  boric  acid,  or  a  solution  of  I  :i,ooo  permanganate  of  potash,  before  an 
instrumental  examination  is  made.  If  time  permits,  it  is  wise  to  give  from 
five  to  ten  grain  doses  of  boric  acid  or  salol,  or  both,  from  three  to  six 
times  a  day,  with  half  a  pint  or  more  of  pure  water,  preferably  hot,  for 
several  days.  This  will  have  a  tendency  to  disinfect  the  bladder  and  the 
urethra.  In  many  cases  it  is  wise  to  give  five-grain  doses  of  quinine  with 
a  pint  of  hot  water,  three  times  a  day,  for  one  or  two  days  before  attempt- 
ing an  instrumental  examination  of  the  urethra.  Many  patients  who  have 
repeatedly  suffered  from  severe  sepsis,  characterized  by  a  chill  known  as 
"urethral,"  followed  by  severe  fever,  after  an  instrumental  examination, 
have  remained  entirely  free  from  these  symptoms  after  future  examina- 
tions of  the  same  character  if  preceded  by  the  use  of  quinine.  The  same  is 
true  regarding  the  gradual  dilatation  of  the  urethra  by  means  of  hard- 
rubber  bougies  or  steel  sounds. 

After  the  necessary  preliminary  preparation  a  moderate  sized  urethral 
sound,  lubricated  with  some  sterile  oily  substance,  is  introduced  with  great 
care  to  the  prostatic  urethra,  but  not  through  it.  If  this  sound  encounters 
any  obstruction  a  smaller  one  is  used  and  the  size  reduced  successively 
until  a  very  small  sound  is  tried.  The  smaller  the  sound,  however,  the 
greater  must  be  the  care  in  its  introduction,  and  whether  the  sound  be  large 
or  small  it  must  always  be  inserted  absolutely  without  force,  for  fear  of 


SURGERY    OF    THE    GENITOURINARY    TRACT 

doing  injury  to  the  delicate  structure  of  the  canal.  If  the  original  sound 
passes  to  the  prostatic  urethra,  then  successive  sounds  are  introduced  until 
the  largest  one  has  been  secured  that  can  be  freely  passed. 

If  any  one  of  the  sounds  used  meets  an  obstruction  it  is  withdrawn 
and  the  depth  of  the  obstruction  carefully  noted;  also  the  size  of  the  largest 
sound  which  will  just  pass  this  obstruction. 
Internal  Urethrotomy. 

The  urethra  is  next  examined  by  means  of  a  bulbed  sound,  the  bulb 
having  approximately  the  shape  of  an  olive.  These  sounds  are  introduced 
in  successive  sizes  until  one  is  reached  which  will  just  pass  the  constriction. 
It  is  then  passed  on  and  may  possibly  encounter  further  constrictions,  which 
it  may  or  may  not  pass.  If  a  smaller  constriction  is  encountered,  smaller 
bulb  sounds  are  used  to  determine  the  size  of  such  obstruction.  The  lo- 
cations of  all  constrictions  are  carefully  noted  as  to  their  depth  and  size. 
After  all  these  facts  have  been  determined  an  Otis  urethrotome  is  intro- 
duced into  the  urethra  and  the  indicator  turned  to  the  point  registering  the 
size  of  the  smallest  stricture,  the  point  of  the  urethrotome  being  inserted 
one-half  inch  beyond  the  location  of  this  stricture  as  determined  by  the 
measurements.  The  concealed  knife  is  directed  either  downwards  or  up- 
wards, so  that  the  cut  will  be  precisely  in  the  median  line.  It  is  then  with- 
drawn a  distance  of  an  inch  or  a  little  more,  when  the  knife  is  forced  into  its 
position  of  concealment.  The  urethrotome  is  then  withdrawn  and  the 
urethra  further  measured  for  other  strictures ;  if  found  they  are  treated  in 
the  manner  just  described. 

After  repeated  examinations  determine  every  portion  of  the  urethra 
to  be  of  normal  size,  as  measured  by  the  bulb  sounds,  and  after  this  exam- 
ination has  indicated  the  urethra  to  be  uniform  in  size,  a  large  urethral 
sound,  No.  30  to  No.  40  French,  according  to  the  size  of  the  patient,  is 
introduced.  If  the  bleeding  is  profuse  a  large  catheter  is  passed  and  the 
cut  surface  is  held  against  this  catheter  by  means  of  rubber  adhesive  straps 
applied  circularly  over  a  padding  of  cotton  at  least  one-half  inch  in  thick- 
ness. In  this  manner  hemorrhage  can  easily  be  controlled.  The  catheter 
is  left  in  place  for  twenty-four  to  forty-eight  hours,  and  the  bladder  irri- 
gated through  it  with  one  of  the  various  antiseptic  solutions  before  men- 
tioned, from  one  to  six  times  each  day,  according  to  the  character  of  the 
urine. 

After-Care, 

The  same  after-treatment  which  has  been  described  for  cystotomy,  so 
far  as  the  administration  of  large  quantities  of  water  and  internal  anti- 
septics are  concerned,  should  be  followed.  After  the  fifth  day  steel  urethral 
sounds,  or  hard  rubber  bougies  are  introduced,  at  first  once  every  three 
or  four  days,  then  every  second  day,  then  every  day,  and  when  the  urethra 
has  been  permanently  dilated  so  that  it  will  comfortably  take  the  largest 
desirable  sound  the  frequency  of  treatment  may  be  reduced  again ;  at  first 
they  are  to  be  used  every  second,  then  every  third,  then  every  fourth  day, 
etc.,  until  presently  they  arc  introduced  but  once  a  month.  This  should  be 
continued  for  many  months  until  the  surgeon  has  evidence  that  no  further 
contraction  will  take  place.  It  is  to  be  remembered  that  a  urethra  which 
has  once  been  strictured  can  be  kept  open  with  much  less  difficulty  and 
with  much  greater  comfort  if  a  series  of  sounds  is  passed  once  a  month, 
than  if  the  stricture  is  permitted  to  reform  and  has  to  be  gradually  dilated. 


SURGERY    OF    THE    GENITOURINARY    TRACT  739 

In  case  it  is  impossible  at  the  primary  examination  to  pass  a  sound  of 
any  size  through  the  stricture  the  patient  should  be  placed  in  bed  and  the 
further  treatment  which  has  been  mentioned  should  be  prolonged.  Patients 
should  also  be  given  hot  baths,  and  after  this  treatment  has  been  continued 
for  some  time  it  will  be  found  that  the  stricture  is  not  so  tight  as  it  was 
at  the  beginning  of  this  attention.  It  will  then  usually  be  possible  to  in- 
troduce a  filiform  bougie.  This  should  be  attached  to  the  end  of  a  conical 
sound,  and  with  this  the  stricture  slightly  distended.  After  this  has  been 
accomplished  the  conical  sound  is  replaced  with  the  urethrotome  and  the 
stricture  cut  as  described  before.  Entire  urethrotomy  is,  however,  not  safe 
in  strictures  located  beyond  the  distal  half  of  the  membranous  portion  of 
the  urethra,  because  the  use  of  this  method  is  likely  to  be  followed  by  se- 
vere extravasation  of  blood  and  sometimes  by  extravasation  of  urine ;  the  lat- 
ter may  result  in  sloughing  of  a  great  amount  of  tissue. 

EXTERNAL  URETHROTOMY. 

In  very  tight  strictures  of  the  membranous  portion  of  the  urethra  it 
is  probably  always  best  to  do  an  external  instead  of  internal  urethrotomy. 
If  the  stricture  is  tight,  however,  internal  urethrotomy  should  always  pre- 
cede the  external,  because  with  a  filiform  bougie  attached  to  the  conical 
sound,  and  later  to  the  urethrotome,  as  has  just  been  described,  it  is  prac- 
tically always  possible  to  split  the  stricture  smoothly  and  with  the  inflic- 
tion of  as  little  unnecessary  traumatism  as  is  possible  to  the  urethra ;  more- 
over, after  internal  urethrotomy  has  been  performed  a  grooved  steel  sound 
can  be  introduced  into  the  urethra  and  then  external  urethrotomy  done 
without  great  difficulty. 

It  is  quite  the  opposite  if  an  external  urethrotomy  is  undertaken  in  a 
tight  stricture  instead  of  first  performing  an  internal  urethrotomy,  because 
the  exceedingly  small  opening  in  the  strictured  portion  of  the  urethra  can 
often  be  found  only  with  the  greatest  amount  of  difficulty,  if  at  all,  and  in 
the  search  for  this  opening  a  great  amount  of  tissue  is  frequently  destroyed. 
Had  the  internal  urethrotomy  been  performed  in  the  same  case  before  the 
external  operation  was  attempted,  all  such  traumatism  would  be  avoided. 
If,  however,  it  is  impossible  to  introduce  a  filiform  bougie  through  the 
stricture,  and  consequently  impossible  to  do  an  internal  urethrotomy,  an 
attempt  may  be  made  at  finding  the  remaining  opening  through  an  external 
incision.  Occasionally  the  surgeon  may  be  more  fortunate  in  his  search 
than  he  could  reasonably  expect,  and  in  this  way  may  discover  the  rem- 
nant of  the  original  canal.  If  this  fails,  however,  after  a  reasonable  at- 
tempt, it  is  best  to  perform  a  suprapubic  cystotomy  and  introduce  a  sound 
into  the  urethra  from  the  side  of  the  bladder,  and  carry  this  down  into  the 
wound  of  the  urethra  to  the  point  of  the  stricture,  and  then  cut  down  ex- 
ternally upon  the  point  of  this  sound.  With  this  guide  it  will  then  be  pos- 
sible to  slit  open  the  stricture.  Preferably  a  fine  probe  is  used,  which  is 
introduced  from  the  upper  portion  of  the  stricture  downward,  the  latter 
being  at  the  end  of  the  sound  which  has  just  been  introduced  from  the 
bladder. 

After-treatment. 

The  wound  is  then  open  and  dressed  with  ordinary  antiseptic  dress- 
ings. The  remnant  of  the  mucous  lining  of  the  urethra  will  begin  to  pro- 


74O  SURGERY    OF    THE    GENITO-URINARY    TRACT 

liferate  and  form  a  covering  of  mucous  membrane  over  the  adjoining  por- 
tion of  the  wound.  Presently  it  will  show  a  tendency  to  close  in  upon  itself 
and  reproduce  the  original  canal.  In  the  meantime  care  should  be  taken 
not  to  permit  the  distal  end  of  the  urethra  becoming  again  contracted. 
This  may  be  prevented  by  the  introduction  of  steel  sounds  once  every  two 
or  three  days.  After  the  urethra  shows  a  tendency  to  close  a  catheter 
should  be  introduced  into  the  bladder  through  the  entire  length  of  the 
urethra  and  the  wound  permitted  to  heal  around  this  catheter.  The  same 
precautions  for  the  dilution  of  urine  which  have  been  described  after  supra- 
pubic  cystotomy  should  be  employed  in  these  cases.  Occasionally  an  ex- 
ternal urethrotomy  is  indicated  by  the  presence  in  the  urethra  of  a  fistula, 
showing  the  existence  of  the  stricture  to  the  distal  side  of  the  fistula.  The 
operation  in  such  case  is  the  same  as  that  which  has  just  been  described. 

RUPTURE  OF  THE  URETHRA. 

The  most  urgent  demand  for  an  external  urethrotomy  is  a  severe 
traumatism  of  the  urethra.  This  is  usually  caused  by  falling  astride  some 
hard  substance,  such  as  a  beam  or  board  in  buildings  being  constructed, 
or  falling  astride  a  wagon  wheel  by  teamsters,  or  falling  upon  the  pummel 
of  the  saddle  by  horsemen,  or  any  other  similar  accident.  The  patient  suf- 
fers severe  pain  in  the  region  of  the  perineum ;  there  is  usually  a  flow  of  a 
variable  amount  of  blood  from  the  urethra ;  there  is  an  obstruction  to  the 
flow  of  urine,  and  upon  introducing  a  catheter  into  the  urethra  it  brings 
blood,  but  no  urine.  If  the  injury  is  recent  these  may  be  all  the  symptoms 
determined.  If  it  has  existed  for  a  longer  time  there  is  severe  ecchymosis, 
there  may  be  marked  edema,  and  there  freqeuntly  is  an  area  of  necrosis, 
which  varies  with  the  severity  of  the  injury  and  length  of  time  that  has 
elapsed  since  its  occurrence. 

If  the  catheter  passes  the  obstruction  and  enters  the  bladder,  this  will 
be  indicated  by  a  flow  of  urine.  In  such  event,  it  is  wise  to  irrigate  the 
bladder  with  some  antiseptic  substance  and  to  leave  the  catheter  in  place, 
for  fear  of  not  being  able  to  reintroduce  it,  for  the  purpose  of  preventing 
extravasation  of  urine  by  the  perfect  draining  of  the  bladder,  and  also  for 
the  purpose  of  acting  as  a  splint  in  directing  the  process  of  healing  in  the 
ruptured  urethra.  If  the  surgeon  is  not  fortunate  enough  to  introduce  the 
catheter  into  the  bladder  without  the  use  of  force,  he  should  abandon  the 
attempt  without  having  increased  the  existing  traumatism,  the  only  rational 
means  then  of  treating  these  cases  being  with  an  external  incision. 

Technique. 

The  patient  is  placed  in  the  lithotomy  position;  the  skin  prepared  for 
operation ;  a  longitudinal  wound  made  upon  the  end  of  the  urethral  sound 
which  has  been  introduced  to  the  point  of  obstruction.  This  sound  will  in- 
dicate the  location  of  the  distal  end  of  the  urethra.  If  it  is  difficult  to  lo- 
cate the  proximal  end  of  the  urethra  this  can  usually  be  effected  by  making 
gradual  pressure  upon  the  bladder,  thus  forcing  out  some  of  the  urine, 
which  will  indicate  the  proximal  end  of  the  canal.  The  incision  is  then 
prolonged  until  it  passes  the  proximal  end  of  the  urethra  for  about  an 
inch.  The  two  extremities  of  the  urethra  are  then  united  by  means  of 
fine  catgut  sutures  for  about  two-thirds  of  their  circumference,  the  most 
superficial  third  being  left  for  drainage.  A  catheter  is  then  introduced 


SURGERY    OF    THE    GENITOURINARY    TRACT  741 

through  the  entire  urethra  into  the  bladder,  and  the  remaining  portion  of 
the  wound  permitted  to  heal  by  granulation. 

It  has  been  our  experience  that  a  complete  union  of  the  urethra  in 
these  cases  can  be  accomplished  much  more  rapidly  and  perfectly  if  the 
entire  circumference  of  the  urethra  is  not  sutured  at  once  at  the  time  of  the 
first  operation. 

After-treatment. 

The  after-treatment  is  the  same  as  before  mentioned.  The  retention 
catheter  is  left  in  place  until  the  wound  in  the  urethra  has  apparently  com- 
pletely healed.  If  the  patient  does  not  come  under  the  surgeon's  care  until 
a  considerable  portion  of  the  urethra  has  become  necrotic,  it  may  be  neces- 
sary to  excise  this  and  bring-  together  portions  of  the  urethra  a  consider- 
able distance  from  each  other.  This,  however,  can  be  done  with  safety  and 
with  comfort  to  the  patient. 

RESECTION  OF  THE  STRICTURED  URETHRA. 

The  same  conditions  may  be  established  if  a  portion  of  the  urethra  has 
been  entirely  destroyed  by  inflammatory  processes,  leaving  a  cicatricial 
stricture,  in  which  a  recovery  of  the  lumen  of  the  urethra  is  impossible. 
In  such  case  the  cicatricial  stricture  is  entirely  excised  and  the  urethra 
above  and  below  united  by  means  of  fine  catgut  sutures,  the  most  super- 
ficial third  of  the  circumference  of  the  urethra  being  again  left  open.  A 
retention  catheter  is  introduced  and  the  wound  dressed  in  the  usual  way. 

Prognosis. 

The  prognosis  in  all  of  these  cases  treated  for  a  long  period  of  time 
after  they  have  apparently  completely  recovered  is  relatively  very  good, 
provided  no  further  gonorrheal  urethritis  occurs.  It  is,  however,  to  be  re- 
membered that  these  patients  should  return  to  the  surgeon  from  time  to 
time,  so  that  he  may  determine  the  tendency  to  recurrence  of  stricture  at  a 
period  when  the  condition  can  be  most  easily  relieved,  and  if  any  such 
tendency  exists,  it  should  be  overcome  by  the  careful  use  of  sounds  before 
it  has  reached  an  advanced  stage. 

VASECTOMY. 

The  excision  of  the  vas  deferens  may  become  necessary  on  account  of 
tuberculosis  of  this  organ,  which  is  not  uncommon,  or  on  account  of  a  ma- 
lignant growth  (sarcoma  extending  to  the  vas  deferens  from  the  testicle 
being  the  most  common  cause),  or  the  operation  may  be  performed  with  a 
hope  of  causing  a  reduction  in  the  size  of  an  hypertrophied  prostate  gland. 
It  is  likely  that  this  operation  will  be  employed  for  the  purpose  of  securing 
.sterility  in  patients  either  physically,  mentally  or  morally  impaired  to  such 
an -extent  as  to  make  their  progeny  dangerous  to  the  community  at  large. 

Technique. 

The  extent  of  the  procedure  will  depend  upon  the  condition  for  which 
it  is  to  be  performed.  If  a  considerable  portion  of  the  vas  deferens  is  dis- 
eased the  incision  should  extend  from  the  external  abdominal  ring  down 
to  the  lower  portion  of  the  scrotum.  The  tissues  of  the  cord  being  exposed, 
the  vas  deferens  will  be  recognized  as  a  hard,  round  cord.  This,  in  case  of 
malignancv.  will  be  removed,  together  with  all  the  tissues  of  the  cord  and 


742  SURGERY    OF    THE    GENITO-URINARY    TRACT 

the  testicle.  In  case  it  is  tubercular  and  the  disease  has  not  penetrated  the 
organ  and  infected  the  surrounding  tissues,  it  is  separated  from  the  adja- 
cent parts  to  a  point  two  centimeters  or  more  beyond  the  affected  portion. 
It  is  then  ligated  with  catgut  at  each  end  and  excised. 

If  the  entire  vas  deferens  is  tubercular  it  should  be  carefully  dissected 
as  far  up  in  the  inguinal  canal  as  is  possible  without  fear  of  breaking  it  off. 
A  syringe  with  a  blunt-pointed  needle  is  then  filled  with  ninety-five  per  cent, 
carbolic  acid.  The  needle  is  introduced  into  the  vas  deferens  and  the  car- 
bolic acid  injected  very  slowly  into  its  lumen.  After  the  acid  has  been  in 
contact  for  five  minutes  the  syringe  is  filled  repeatedly  with  strong  alco- 
hol, which  is  also  injected  through  the  lumen  of  the  vas  deferens  in  order 
to  prevent  the  carbolic  acid  from  causing  too  much  destruction. 

Should  the  operation  be  intended  only  for  the  interruption  of  the  con- 
tinuity of  the  canal,  a  small  incision  two  centimeters  in  length  is  made  op- 
posite the  external  abdominal  ring,  the  tissues  of  the  cord  are  brought  into 
the  incision,  the  vas  deferens  is  separated  from  the  other  structures  of  the 
cord,  two  catgut  ligatures  are  applied  a  centimeter  apart,  and  the  interven- 
ing portion  excised.  The  tissues  of  the  cord  are  then  replaced  and  the 
wound  in  the  skin  closed  with  one  stitch. 

Regarding  the  effect  of  this  operation  for  the  relief  of  hypertrophy  of 
the  prostate  gland,  we  would  say  that  there  are  undoubtedly  certain  patients 
who  are  permanently  benefited  by  this  form  of  treatment.  It  is,  however, 
impossible  to  determine  beforehand  which  patients  will  be  so  improved, 
and  consequently  it  is  impossible  to  make  a  reliable  prognosis.  The  opera- 
tion in  itself  is  simple;  it  can  easily  be  performed  under  cocaine  anesthesia; 
it  is  not  accompanied  by  pain ;  and  results  in  no  deformity.  All  of  these 
reasons  make  it  one  which  should  not  be  condemned,  although  the  relative 
number  of  permanent  recoveries  is  not  sufficient  to  warrant  its  general 
adoption. 

PROSTATECTOMY. 

This  operation  has  grown  greatly  in  favor  during  the  past  few  years, 
principally  because  attention  has  been  paid  to  its  careful  technical  develop- 
ment. It  is  performed  entirely  for  the  removal  of  hypertrophied  prostate 
glands.  We  will  only  describe  the  perineal  method,  because  the  suprapubic 
method  virtually  corresponds  to  the  operation  for  suprapubic  cystotomy,  to 
which  is  added  the  enucleation  of  one  or  more  lobes  of  the  enlarged  prostate 
gland  projecting  into  the  bladder.  For  all  cases  of  prostatic  enlargement 
in  which  there  is  not  a  distinct  projecting  lobe  into  the  bladder,  we  would 
perform  the  perineal  operation. 

In  the  consideration  of  this  operation  it  must  be  remembered  that  pa- 
tients upon  whom  it  is  performed  are  usually  advanced  in  years,  because 
hypertrophy  of  the  prostate  gland  occurs  most  frequently  at  such  time. 
There  has  been  an  obstruction  to  the  passage  of  urine,  which  has  usually 
resulted  in  the  accumulation  of  residual  urine  in  the  bladder,  predisposing 
to  infection  and  consequent  cystitis.  Many  of  these  patients  have  infected 
their  bladders  mechanically  by  the  use  of  septic  catheters ;  in  many  these 
conditions  have  resulted  in  the  formation  of  stone;  in  many,  again,  the  in- 
fection has  advanced  by  one  or  both  ureters  into  the  pelvis  of  the  kidney, 
giving  rise  to  a  pyelitis ;  and  still  again  many  are  found  suffering  from  a 
chronic  nephritis,  which  is  not  uncommon  in  patients  advanced  in  years, 
though  there  may  be  no  direct  mechanical  cause  for  its  occurrence.  All 


PLATE  CXXXIII. 

PROSTATECTOMY. 

A  horseshoe  shayed  incision  is  shown  with  the  two  branches  opposite  the  tuber- 
ischii.  The  flap  is  drawn  backward  by  a  vaginal  speculum  (d)  :  the  wound  is  held 
open  laterally  by  the  retractors  (ee)  ;  the  urethra  is  seen  deep  in  the  wound  anteriorly 
at  (c)  :  the  prostate  gland  (b)  is  drawn  downward  by  means  of  the  cat's-paw 
retractor  (a). 


SURGERY    OF    THE    GENITOURINARY    TRACT  745 

these  facts  would  indicate  that  this  operation,  as  a  rule,  is  done  on  a  class 
of  patients  who  are  not  well  fitted  to  endure  any  serious  surgical  under- 
taking, which  must  of  course  be  borne  in  mind  when  this  operation  is  sug- 
gested. The  facts  which  are  in  favor  of  this  operation  in  those  whose  gen- 
eral condition  is  not  good  are: 

1.  That  the  patient  will  be  relieved  of  pain. 

2.  The  drainage  of  the  bladder  which  follows  the  operation  relieves 
the  urinary  obstruction  and  at  the  same  time  prevents  further  septic  ab- 
sorption from  residual  urine. 

3.  The  bladder  is  accessible  to  irrigation  after  this  operation,  so  that 
any  septic  material  which  may  be  secreted  from  its  walls  can  be  frequently 
washed  away. 

4.  The  patient  is  not  exposed  to  the  likelihood  of  infection  in  the  fu- 
ture, which  is  almost  inevitable  if  he  is  compelled  to  resort  to  the  daily  use 
of  a  catheter  for  the  purpose  of  evacuating  the  bladder. 

It  remains  now  to  reduce  to  the  minimum  the  amount  of  traumatism 
required  for  the  removal  of  the  enlarged  prostate  gland.  We  believe  that 
the  operation  herewith  described  fills  this  requirement. 

Preparation  for  Operation. 

It  is  important  that  patients  about  to  undergo  this  operation  should  be 
carefully  prepared  in  the  manner  described  in  connection  with  suprapubic 
cystotomy.  These  cases  are  almost  all  chronic  in  character  when  they  reach 
the  hands  of  the  surgeon ;  consequently  a  few  weeks  spent  in  securing  as 
aseptic  a  condition  of  their  bladders  as  possible  is  not  of  much  importance 
to  them.  It  is  not  so  much  of  a  hardship  to  a  man  to  postpone  his  relief 
for  a  few  weeks,  after  he  has  suffered  for  a  long  time,  as  it  would  be  if 
his  suffering  were  acute,  and  we  believe  that  success  depends  to  a  very  large 
extent  upon  the  careful  preparatory  treatment. 

Technique. 

Before  beginning  the  operation,  the  bladder  is  carefully  irrigated  with 
one  of  the  mild  antiseptic  fluids  mentioned  before  in  connection  with  bladder 
surgery,  until  the  fluid  returns  perfectly  clear.  The  bladder  is  then  com- 
pletely emptied  by  placing  a  soft  rubber  catheter  so  that  it  will  act  as  a 
siphon,  and  by  making  pressure  upon  the  bladder  above  the  pubis.  The  soft 
rubber  catheter  is  then  removed  and  a  steel  sound  introduced  to  the  pro- 
static  portion,  but  not  through  it,  to  act  as  a  guide  in  locating  the  urethra. 
A  horseshoe-shaped  incision  is  then  made  from  a  point  opposite  the 
tuberosity  of  the  ischium  on  one  side  to  that  on  the  other,  the  convex  por- 
tion extending  across  the  perineum,  as  indicated  in  Plate  CXXXIII.  With  a 
finger  in  the  rectum  and  the  steel  sound  in  the  urethra  one  can  readily  and 
safely  make  the  dissection  forward  until  the  entire  lower  surface  of  the 
prostate  gland  is  exposed,  as  shown  in  this  plate.  A  few  insignificant  ves- 
sels will  be  encountered,  and  from  each  side  there  will  be  one  or  more  di- 
visions of  the  internal  pubic  artery  which  will  bleed  freely,  but  it  can  be 
grasped,  either  before  or  after  division,  with  hemostatic  forceps  and  ligated 
at  once  in  order  to  leave  the  space  entirely  free.  All  of  the  smaller  vessels 
may  be  grasped  and  also  ligated,  the  important  point  in  this  portion  of  the 
operation  being  the  complete,  careful  exposure  of  the  prostate  gland.  A 
sharp-toothed  cat's-paw  retractor  is  then  caught  in  one  lobe  of  the  gland 
and  the  latter  drawn  downward.  With  a  sharp  scalpel  the  capsule  of  the 
other  lobe  is  then  incised  deeply,  care  being  taken  not  to  approach  the 


746  SURGERY    OF    THE    GENITOURINARY    TRACT 

middle  portion  of  the  gland.  A  second  retractor  of  the  same  kind  is  then 
inserted  into  the  lobe  which  has  just  been  incised,  and  the  gland  kept  drawn 
down  while  a  second  deep  incision  is  made  through  the  capsule  of  the  sec- 
ond lobe.  While  the  gland  is  still  held  downwards  by  means  of  the  cat's- 
paw  retractor,  a  finger  is  introduced  into  the  incision  which  has  just  been 
made  and  one  lobe  of  the  gland  freed  from  its  capsule,  regard  being  taken 
not  to  approach  the  median  portion.  The  retractor  is  then  again  changed 
to  the  other  lobe,  and  the  second  lobe  is  enucleated  with  the  finger,  care 
being  again  taken  not  to  approach  the  middle  portion  until  the  lobe  has  been 
entirely  freed.  In  this  manner  a  considerable  amount  of  annoying  hem- 
orrhage is  avoided,  which  comes  from  the  submucous  veins  at  the  neck  of 
the  bladder.  In  case  the  middle  lobe  is  approached  at  first,  these  veins  are 
likely  to  cause  a  sufficient  amount  of  bleeding  to  cloud  the  field  of  operation. 

One  finger  is  now  introduced  behind  each  lobe,  and  by  bringing  the 
two  fingers  together  posteriorly,  the  entire  gland  can  usually  be  rolled  out 
forward.  The  anterior  attachment  is  then  cut  away  with  scissors,  in  order 
not  to  disturb  the  anterior  portion  of  the  prostatic  urethra  unnecessarily. 
A  gauze  pad  is  inserted  at  once  to  make  a  slight  amount  of  pressure,  which 
will  cause  the  bleeding  to  subside  readily. 

A  finger  is  then  introduced  into  the  bladder  in  order  to  determine  the 
presence  of  one  or  more  stones.  Occasionally,  after  a  thorough  examina- 
tion of  the  bladder  with  a  steel  sound  has  failed  to  determine  stones,  the 
digital  examination  after  the  removal  of  the  prostate  gland  will  still  dem- 
onstrate their  presence.  If  stones  are  found  the  surgeon  should  determine 
whether  the  opening  in  the  bladder  is  sufficiently  large  to  permit  their  ex- 
traction. If  not  then  an  incision  is  made  posteriorly  until  the  desired  size 
has  been  obtained.  The  stones  are  then  removed  in  the  ordinary  manner. 
In  ordinary  cases  all  that  remains  to  be  done  is  the  introduction  of  a  rubber 
tube,  with  numerous  small  perforations  near  the  end,  to  the  fundus  of  the 
bladder.  This  should  be  stitched  into  the  angle  of  the  wound.  A  piece  of 
iodoform  gauze  may  then  be  tamponed  against  the  remaining  portion  of  the 
capsule  of  the  prostate  gland  and  permitted  to  protrude  from  the  wound 
of  the  perineum  near  the  point  at  which  the  drainage  tube  issues.  A  few 
stitches  are  then  applied  to  replace  the  flap. 

We  believe  that  it  is  best  not  to  suture  the  flap  too  tightly,  because  there 
will  be  considerable  oozing,  and  if  there  is  a  sufficient  amount  of  space 
for  drainage  to  take  place  the  patient  will  be  saved  the  possibility  of  the 
accumulation  of  wound  secretion.  If  the  bladder  has  been  severely  infected 
we  believe  it  is  better  to  introduce  two  drainage  tubes  a  little  smaller  in 
size  to  the  fundns  of  the  bladder  so  that  irrigation  may  be  accomplished  by 
injecting  the  irrigating  fluid  through  one  tube  and  permitting  it  to  escape 
through  the  other  after  the  operation.  In  case  there  should  be  consider- 
able hemorrhage  from  the  capsule — which,  however,  is  not  common — this 
may  be  controlled  by  the  application  of  a  few  hemostatic  forceps,  which  are 
permitted  to  protrude  through  the  wound,  and  which  may  be  removed  after 
twelve  or  twenty-four  hours  with  safety.  If  there  is  much  oozing  the  space 
may  be  tamponed  with  sufficient  iodoform  gauze  to  overcome  it,  but  it  does 
not  frequently  happen  that  the  tissues  require  this  form  of  tamponing. 

After-treatment. 

The  bladder  should  be  irrigated  with  one  of  the  various  mild  anti- 
septic fluids  from  one  to  six  times  a  day,  according  to  the  condition  of  the 
viscus  wall.  The  iodoform  gauze  is  withdrawn  after  the  second  or  third 


SURGERY    OF    THE    GENITOURINARY    TRACT  747 

day,  and  from  the  fifth  to  the  tenth  day  the  rubber  drainage  tube  is  re- 
moved. In  many  cases  the  patient  has  no  difficulty  after  this  time  with 
evacuating  the  bladder  normally,  but  if  the  flow  of  urine  is  not  normal  it 
is  wise  to  introduce  a  soft  rubber  catheter  through  the  urethra  into  the 
bladder  for  a  few  days.  It  is  well  to  remove  it  every  second  or  third  day  to 
see  whether  the  normal  conditions  have  been  established,  and  if  they  have 
not,  the  catheter  may  be  replaced.  During  this  period  it  is  well  to  give 
some  mild  antiseptic  internally  and  to  give  the  patient  large  quantities  of 
pure  water,  in  order  to  dilute  the  urine.  It  is  well  to  encourage  him  to  sit 
up  the  second  or  third  day  after  the  operation,  and  to  get  out  of  bed  as 
soon  as  possible,  because  men  at  this  age  do  not  bear  confinement  very  well. 

Prognosis. 

Bearing  in  mind  the  condition  of  these  patients,  aside  from  that  of  the 
prostate  gland,  they  withstand  this  operation  remarkably  well,  and  the  dif- 
ference in  the  comfort  of  the  patient  and  the  improvement  in  his  general 
condition  is  very  marked.  In  many  cases  the  free  drainage  seems  to  im- 
prove the  function  of  the  kidneys  decidedly,  so  that  after  a  few  months  a 
marked  albuminuria  may  almost  entirely  disappear.  The  fact  that  a  con- 
stant source  of  septic  infection  has  been  removed  is  of  very  great  impor- 
tance to  the  general  health  of  the  patient.  We  believe  this  operation  will 
add  many  years  to  the  lives  of  these  sufferers. 

Complications. 

Occasionally  it  will  be  found  that  the  existing  adhesions  prevent  the 
enucleation  of  any  considerable  portion  of  the  prostate  gland,  and  that  in 
order  to  remove  it  in  the  manner  just  described  it  will  be  necessary  to 
produce  too  severe  a  traumatism ;  consequently  if  it  is  found  impossible  to 
enucleate  the  lobes  of  the  prostate  as  described,  the  following  method  should 
be  substituted : 

The  operation  is  performed  as  described  above  to  the  point  of  enuclea- 
tion. This  is  attempted,  but  if  it  proves  unsuccessful,  the  sharp-toothed 
cat's-paw  retractor  is  applied  to  one  lobe,  as  indicated  in  Plate  CXXXIII,  and 
the  substance  of  the  gland  removed  piecemeal  with  cutting  forceps.  The  ex- 
tent to  which  it  has  to  be  removed  can  easily  be  determined  by  inserting  the 
finger  into  the  field  of  operation  from  time  to  time.  The  operation  is  more 
tedious  than  enucleation,  but  much  safer  than  in  cases  in  which  enucleation 
cannot  be  readily  accomplished.  The  drainage  of  the  bladder  and  the  after- 
treatment  are  the  same  as  described  before. 

Until  one  has  become  thoroughly  familiar  with  the  perineal  removal 
of  the  prostate  gland  it  is  probably  best  to  follow  the  above  method,  be- 
cause the  entire  operation  is  performed  virtually  in  plain  view  of  the  op- 
erator, which  is,  however,  quite  unnecessary  after  one  has  acquired  a  clear 
comprehension  of  the  conditions. 

The  following  operation  is  much  less  difficult ;  is  combined  with  much 
less  trauma ;  it  can  be  performed  in  one-fourth  the  time  required,  which  is 
an  important  element ;  and  the  results  are  proportionately  more  satisfactory. 
The  operation  combines  all  of  the  advantages  of  the  suprapubic  prostatec- 
tomy with  perineal  drainage  and  does  not  contain  any  of  the  many  disad- 
vantages of  the  suprapubic  route. 

Technique. 

A  grooved   sound  is  introduced  into  the  urethra,  then  an  incision  is 


748  SURGERY    OF    THE    GENITOURINARY    TRACT 

made  from  a  point  half  way  between  the  scrotum  and  the  anus  to  one  half 
way  between  the  anus  and  the  tuber  ischii.  This  incision  is  carried  into  the 
membranous  urethra. 

Then  an  old  fashioned  lithotomy  knife  with  a  knob  end  is  placed  in  the 
groove  of  the  sound  and  the  sound,  together  with  the  knife,  is  carried  into 
the  bladder,  splitting  open  the  membranous  and  the  prostatic  urethra 
throughout  their  course  posteriorly.  The  ringer  is  then  introduced  into 
the  bladder  and  the  two  lobes  of  the  gland  are  enucleated  precisely  as  one 
would  do  this  in  suprapubic  prostatectomy.  A  drainage  tube  is  introduced 
and  the  space  from  which  the  gland  has  been  removed  is  tamponed  with 
gauze.  If  there  is  troublesome  hemorrhage  the  bladder  is  pulled  down  with 
the  finger  and  hemostatic  forceps  are  applied  to  the  edge  of  the  capsule 
and  these  are  left  in  place  for  twelve  hours,  when  they  are  loosened.  They 
are  not  withdrawn  until  the  following  day.  It  is  but  rarely  necessary  to 
apply  these  forceps. 

In  cases  in  which  the  gland  cannot  be  enucleated  it  may  be  gnawed 
away  with  the  Ferguson  punch-forceps. 

The  entire  operation  can  be  completed  leisurely  in  fifteen  minutes,  while 
a  rapid  operator  can  accomplish  it  in  one-fourth  of  this  time  with  safety. 

PROSTATOTOMY. 

This  operation  is  performed  for  the  relief  of  abscess  of  the  prostate 
gland.  In  young  individuals  with  an  infection  of  the  gland,  due  to  specific 
urethritis,  it  is  often  found  that  the  gland  is  filled  with  multiple  abscesses, 
which  will  keep  the  patient  in  a  slightly  septic  condition  for  a  long  time. 
This  infection  may  progress  to  form  larger  abscesses,  but  these  usually 
have  for  their  exciting  cause  the  introduction  of  steel  sounds  or  bougies. 
The  abscess  may  increase  in  size  to  such  an  extent  as  to  produce  a  swelling 
in  the  region  of  the  perineum,  or  it  may  produce  a  fluctuating  tumor  in 
the  rectum.  This  is  accompanied  by  severe  pains  and  symptoms  of  acute 
suppuration.  A  large  abscess  that  causes  swelling  in  the  region  of  the 
perineum  should  be  opened  through  a  perineal  section,  being  careful  not  to 
injure  either  the  rectum  or  the  urethra.  It  is  well  to  make  the  incision 
quite  into  the  prostate  gland,  to  curette  away  the  infectious  material,  and 
tampon  the  cavity  with  iodoform  gauze.  If  the  fluctuation  can  be  discov- 
ered by  digital  examination  through  the  rectum,  the  incision  just  described 
may  be  used,  or  the  swelling  in  the  rectum  may  be  exposed  by  the  use  of 
retractors  and  the  abscess  opened  into  the  rectum  by  the  use  of  the  actual 
cautery.  In  this  event,  the  opening  should  be  made  large  enough  to  insure 
permanent  drainage.  The  opening  will  increase  in  size  if  it  has  been  made 
by  the  cautery,  because  the  eschar  which  is  formed  throughout  the  circum- 
ference of  the  opening  will  fall  off  as  healing  progresses,  and  thus  increase 
this  aperture. 

Much  has  been  said  against  the  opening  of  prostatic  abscesses  into  the 
rectum  for  fear  of  infection.  If  the  wound  has  been  made  as  just  described, 
and  if  the  patient  has  received  proper  preliminary  treatment,  consisting  in 
the  administration  of  two  ounces  of  castor  oil  for  two  successive  days  pre- 
vious to  the  operation,  with  thorough  repeated  flushings  of  the  bowel  be- 
fore the  operation,  and  if  the  operation  is  followed  by  proper  after-treat- 
ment, consisting  in  the  administration  of  a  saline  laxative  daily  and  thor- 
ough flushing  after  the  evacuation  of  the  bowels,  then,  according  to  our  ex- 


SURGERY    OF    THE    GENITOURINARY    TRACT  749 

perience,  the  results  will  be  perfectly  satisfactory.  It  is  quite  different  if 
the  abscess  is  simply  incised,  especially  if  the  preliminary  and  after-treat- 
ment are  not  carried  out  with  care. 

In  the  presence  of  multiple  small  abscesses  of  the  prostate  gland,  re- 
sulting- from  repeated  infections  from  gonorrheal  urethritis,  the  gland  is 
exposed  as  in  the  operation  described  for  perineal  prostatectomy.  Then  it  is 
drawn  down,  as  indicated  in  Plate  CXXXIII,  and  a  deep  incision  made 
transversely  across  each  lobe  of  the  prostate,  and  this  is  carefully 
tamponed  with  iodoform  gauze.  A  small  rubber  drainage  tube  is  intro- 
duced to  each  lobe  of  the  gland,  but  not  into  it,  and  the  wound  closed  with 
sutures,  with  the  exception  of  the  two  lower  angles  through  which  the  rub- 
ber drainage  tube  and  the  iodoform  gauze  issue. 

Prognosis. 

This  operation  may  result  in  the  complete  relief  of  the  patient,  espe- 
cially if  he  has  not  the  misfortune  of  acquiring  a  further  gonorrheal  ureth- 
ritis. In  many  cases,  however,  the  recovery  is  not  permanent,  and  it  will 
be  necessary  to  perform  a  prostatectomy  in  order  to  give  permanent  relief. 

EPIDIDYMECTOMY. 

In  a  majority  of  cases  of  tuberculosis  of  the  testicles  they  are  in- 
volved secondarily,  the  primary  tuberculosis  being  in  the  epididymis,  and 
in  many  cases  in  which  the  testicle  is  supposed  to  be  tuberculous  a  careful 
examination  will  reveal  the  fact  that  the  disease  is  still  confined  to  the 
epididymis.  If  this  is  the  case,  it  is,  of  course,  not  necessary  to  disturb 
the  testicle  during  the  operation,  which  should  simply  consist  in  making 
a  wedge-shaped  excision  of  the  epididymis,  together  with  the  vas  deferens, 
which  is  usually  involved,  and  to  close  the  defect  with  fine  catgut  sutures. 
Even  if  there  is  a  moderate  infection  of  the  testicle,  a  conical  excision  of  the 
diseased  area  may  be  made  when  the  epididymis  is  removed,  and  the  defect 
closed  with  buried  catgut  sutures.  It  is  only  in  case  of  multiple  tubercular 
foci  in  the  testicle,  in  which  it  seems  impossible  to  preserve  any  portion 
of  the  organ,  in  which  the  multiple  puncture  with  the  actual  cautery  is  indi- 
cated, because  with  this  method  it  is  possible  to  preserve  a  remnant  of  the 
organ,  even  if  apparently  the  entire  gland  has  been  destroyed  by  the  tuber- 
culosis. 

It  is  plain  that  a  wound  made  in  this  manner  cannot  heal  so  quickly  as 
a  clean  cut  one,  but  the  patient  is  very  willing  to  undergo  the  necessary 
annoyance  in  order  to  secure  the  resulting  benefit. 

The  cicatricial  tissue  which  develops  as  a  result  of  the  cauterization 
seems  to  do  much  to  prevent  the  further  destruction  of  the  organ  by  tuber- 
culosis. 

If  the  vas  deferens  is  involved  in  the  tuberculous  process  it  should  be 
excised.  It  is  not  difficult  to  follow  this  structure  to  a  point  near  the  blad- 
der by  slowly  drawing  it  up  into  the  wound  and  freeing  it  from  the  sur- 
rounding tissues  by  pressure  with  a  moist  gauze  pad.  The  external  in- 
cision may  be  carried  to  a  point  just  outside  the  external  abdominal  ring. 
The  diseased  portion  of  the  vas  deferens  is  somewhat  uneven  and  nodular. 
It  is  well  to  remove  the  structure  to  a  point  some  distance  beyond  the  por- 
tion that  is  diseased.  In  order  not  to  have  the  vas  severed  too  near  the  dis- 
eased portion  it  is  well  to  make  the  dissection  very  slowly,  and  then  place 


75O  SURGERY    OF    THE    GENITOURINARY    TRACT 

a  pair  of  hemostatic  forceps  at  the  point  where  it  is  desired  to  sever  the 
structure,  to  apply  a  ligature  at  this  point  and  then  cut  just  proximally  to 
the  ligature.  If  the  seminal  vesicles  are  left  in  place  and  also  the  testicles 
the  patient's  sexual  life  will  not  be  disturbed  in  the  least  by  this  operation, 
even  if  both  vasa  deferencia  are  removed. 

This  fact  is  important  in  connection  with  this  operation  when  per- 
formed for  the  purpose  of  securing  sterility  of  the  male  for  sociological 
reasons. 

It  has  been  suggested  to  perform  vasectomy  for  the  sterilization  of 
habitual  criminals,  epileptics,  idiots  and  other  degenerates  for  the  protec- 
tion of  the  community. 

In  this  operation  it  is  not  necessary  to  make  so  extensive  an  operation. 
The  skin  over  the  vas  deferens  may  be  anesthetized  by  the  injection  of  a  one 
per  cent,  solution  of  cocaine,  injected  also  about  the  vas,  which  is  brought 
out  through  an  incision  two  cm.  long;  it  is  ligated  twice  at  a  distance  of 
one  cm.  apart  and  then  severed.  The  wound  is  closed  with  one  or  two 
fine  catgut  sutures  and  the  operation  repeated  on  the  opposite  side. 

The  operation  is  justified  by  the  fact  that  the  community  gains  enor- 
mously while  the  individual  loses  nothing.  He  is  not  exposed  to  any  risk, 
suffers  no  pain  and  is  not  inconvenienced  in  any  other  way  except  that 
parentage  is  prevented,  which  in  these  classes  is  never  of  any  harm  to  the 
individual. 

UNITING  OF  VAS  DEFERENS  ACCIDENTALLY     SEVERED. 

In  case  a  vas  deferens  is  accidentally  severed  during  the  progress  of 
any  operation  it  may  be  united  by  passing  two  sutures  of  fine  double  chromic 
catgut  from  without  into  the  lumen  of  one  segment,  then  into  the  lumen  of 
the  other  segment,  then  out  through  its  wall  and  tying  loosely  one  on  each 
side,  and  then  applying  a  few  fine  sutures  to  the  edges  of  the  vas. 

The  catgut  in  the  lumen  acts  as  a  splint  and  secures  a  continuous  pas- 
sage through  the  vas. 

ABSCESS  OF  SEMINAL  VESICLES. 

In  many  cases  the  infection  is  limited  to  the  seminal  vesicles.     This 
may  be  unilateral,  or  it  may  affect  both  sides.     If  the  infection  has  become 
chronic  nothing  short  of  surgical  treatment  will  give  permanent  relief. 
Technique. 

The  same  operation  must  be  performed  that  has  just  been  described 
as  prostatotomy,  differing  in  that  the  infected  vesicle  is  located  with  the 
finger  in  the  rectum,  and  that  it  is  carefully  and  thoroughly  removed  with 
a  moderately  sharp  curette.  The  space  is  then  drained  as  in  prostatotomy. 

CASTRATION. 

This  operation  is  indicated  for  the  relief  of  malignant  disease  of  the 
testicle,  for  gangrene,  or  for  traumatism,  which  would  inevitably  result  in 
gangrene  of  the  organ,  for  destructive  suppuration,  and  for  very  extensive 
unilateral  tuberculosis. 

If  tuberculosis  occurs  in  both  organs  simultaneously,  or  in  the  remain- 
ing organ  after  the  other  has  been  removed  for  any  reason,  we  have  never 


SURGERY    OF    THE    GENITOURINARY    TRACT  751 

found  it  necessary  to  perform  this  operation,  but  have  substituted  the  de- 
struction of  the  diseased  portion  by  means  of  the  actual  cautery.  Even  in 
cases  in  which  only  a  very  slight  amount  of  the  tissue  may  be  preserved  we 
have  found  this  of  great  value  to  the  patient.  This  is  true  even  in  cases 
in  which  it  was  necessary  to  remove  the  epidiclymis,  together  with  the  vas 
deferens.  So  long  as  it  was  possible  to  preserve  the  seminal  vesicles  there 
has  been  no  mental  depression  in  these  cases  on  account  of  the  partial  de- 
struction of  the  testes  with  the  actual  cautery,  together  with  the  removal 
of  the  vas  deferens  on  both  sides.  It  is  quite  different  in  case  of  double 
castration  in  patients  too  young  to  have  passed  beyond  the  virile  period  nor- 
mally. Double  castration,  in  our  experience,  has  resulted  in  permanent  relief 
from  urinary  obstruction  due  to  hypertrophy  of  the  prostate  gland  in  about 
fifty  per  cent,  of  all  cases  in  which  we  have  made  use  of  this  method.  There  is, 
however,  no  definite  guide  that  will  indicate  which  cases  are  likely  to  be 
benefited.  Moreover,  the  operation  results  in  a  deformity  which  is  very  re- 
pulsive to  many  patients,  even  though  past  the  virile  stage. 

It  seems  as  though  this  method  should  receive  definite  recognition,  but 
since  perineal  prostatectomy  has  been  so  much  simplified,  and  its  safety  so 
greatly  enhanced,  it  appears  doubtful  whether  castration  for  the  relief  of 
prostatic  hypertrophy  will  continue  to  be  employed  to  any  great  extent. 

TUMORS  OF  THE  TESTICLE. 

The  most  common  forms  of  tumor  of  the  testicle  are  sarcoma,  enchon- 
droma  and  teratoma.  All  other  forms  may  occur,  but  are  not  common. 
Tumors  should  be  differentiated  from  gumma,  inflammatory  swelling,  hydro- 
cele  with  an  unusually  tense  sac,  or  a  sac  which  has  undergone  calcareous 
degeneration,  scrotal  hernia  with  incarcerated  omentum,  tuberculosis  of  the 
testicle  and  epididymis  and  simple  hyperplasia  of  the  testicle. 

The  most  common  error  occurs  in  connection  with  gumma  of  the  tes- 
ticle, which  is  not  a  very  unusual  condition.  It  is  frequently  necessary  to 
place  the  patient  under  vigorous  antisyphilitic  treatment  for  a  few  weeks 
in  order  to  positively  clear  up  the  diagnosis.  It  seems  wise  in  all  of  these 
cases  to  test  the  patient  carefully  with  Ehrlich's  remedy  606  before  making 
a  positive  diagnosis  of  a  malignant  growth,  as  this  remedy  acts  so  promptly 
that  even  if  malignancy  is  present  the  patient  will  lose  little  because  of  the 
delay.  Tuberculosis  can  usually  be  eliminated  more  easily  because  of  the 
nodular  condition  of  the  swelling  and  the  tendency  to  breaking  down  of 
portions.  There  is  usually  also  a  tubercular  history,  and  the  progress  of 
the  disease  is  relatively  slo\v. 

The  differentiation  between  hernia  and  hydrocele  has  been  discussed  in 
connection  with  these  subjects. 

Technique. 

An  incision  is  made  through  the  skin  from  the  external  abdominal 
ring  downward  to  a  point  near  the  lower  edge  of  the  scrotum ;  then  the  en- 
tire organ,  together  with  the  tunica  vaginalis,  is  enucleated.  A  pair  of 
heavy  clamp  forceps  is  applied  just  outside  of  the  external  abdominal  ring, 
then  the  tissues  of  the  cord  are  dissected  out  in  the  inguinal  canal.  If  the 
tumor  is  quite  advanced,  the  incision  in  the  skin  may  be  carried  to  a  point 
opposite  the  internal  abdominal  ring,  and  may  be  carried  through  the  deep 
fascia  and  the  fascia  of  the  external  oblique  abdominal  muscle,  exposing 


752  SURGERY    OF    THE    GENITOURINARY    TRACT 

the  tissues  of  the  cord  throughout  the  entire  distance  of  the  inguinal  canal. 
In  this  case  the  tissues  of  the  cord  are  dissected  out  to  this  point. 

The  vas  deferens  is  then  separated  from  the  remaining  tissues  of  the 
cord,  ligated  with  catgut,  cut  and  permitted  to  retract  within  the  internal  ab- 
dominal ring.  The  remaining  structures  of  the  cord  are  then  separated 
and  the  various  larger  vessels  ligated  and  cut  separately  and  successively 
permitted  to  retract  beyond  the  internal  abdominal  ring.  Then  the  remain- 
ing portion  of  the  cord  is  ligated  en  masse  and  cut.  In  this  manner  one 
may  easily  guard  against  secondary  hemorrhage.  All  bleeding  points  are 
carefully  caught  and  ligated.  A  small  drain  is  inserted  in  the  lower  angle 
of  the  wound  in  order  to  prevent  the  accumulation  of  serum  from  the  large 
surface.  The  wound  is  then  sutured  and  an  ordinary  dressing  applied  and 
held  in  place,  preferably  by  a  properly  constructed  suspensory  bandage. 

If  the  malignant  growth  has  invaded  the  skin,  or  the  other  side  of  the 
scrotum,  the  same  should  be  entirely  removed,  provided  it  seems  likely  that 
the  disease  is  still  localized.  Unfortunately  metastases  usually  occur  in 
these  cases  before  they  have  advanced  to  the  point  of  invading  the  sur- 
rounding tissues ;  hence  the  prognosis  is  usually  hopeless  when  this  condi- 
tion is  present. 

If  the  operation  is  performed  without  unnecessary  traumatism,  it  is 
usually  not  followed  by  any  severe  degree  of  shock.  In  patients  advanced 
in  age,  however,  the  shock  is  sometimes  quite  considerable,  and  many  sur- 
geons have  reported  the  occurrence  of  acute  melancholia,  which,  it  seemed, 
was  not  due  to  sepsis  in  some. 

In  young  patients  this  operation  very  frequently  gives  rise  to  mental 
depression,  and  should  not  be  employed  if  there  is  any  possibility  of  avoid- 
ing it. 

In  some  cases  the  deformity  may  be  corrected  by  inserting  into  the 
scrotum  a  properly  shaped  mass  of  paraffin  or  a  hollow  structure  com- 
posed of  celluloid  of  the  same  form. 

One  of  these  devices  seems  to  be  of  considerable  value  to  neurotic  sub- 
jects, and  if  a  patient  seems  inclined  to  be  neurotic  it  may  be  well  to  make 
use  of  this  plan  at  the  time  of  the  original  operation. 


PART    IX. 


SURGERY  OF  THE  FEMALE  PELVIS. 

OVARIAN  TUMORS. 

The  early  history  in  cases  of  ovarian  tumors  is  usually  negative,  the 
growth  being  discovered  by  accident.  Among  educated  people  in  the  higher 
classes  of  society  such  a  tumor  is  usually  discovered  during  a  careful  physical 
examination  made  by  the  family  physician  in  the  course  of  some  illness 
of  the  patient  which  has  no  relation  to  the  presence  of  the  tumor.  Thorough 
physical  examinations  are  now  so  commonly  made  that  in  this  class  of  pa- 
tients the  growth  is  usually  discovered  before  it  has  advanced  to  any  great 
size. 

It  is  quite  different  among  patients  belonging  to  the  so-called  lower 
classes  of  society.  Among  these  ovarian  tumors  are  usually  not  discovered 
until  they  have  attained  considerable  size,  when  the  patient  discovers  the 
growth  herself.  In  a  large  majority  a  history  of  peritonitis  at  some  time 
in  the  past  can  be  established,  provided  the  conditions  are  favorable  for 
obtaining  a  perfect  history.  In  many  cases  the  time  of  such  peritonitis  is 
so  remote  that  it  becomes  necessary  to  inquire  from  the  parents  regarding 
the  patient's  sickness  during  childhood. 

The  peritonitis  of  early  youth  and  childhood  is  usually  due  to  appendi- 
citis or  typhoid  fever,  and  occasionally  to  scarlet  fever.  Later  on  in  life 
it  is  more  commonly  dependent  upon  a  specific  infection  through  the  uterus 
and  tubes,  and  still  later  to  puerperal  infection  following  childbirth  or 
abortion. 

These  infections  are  certain  to  leave  the  ovaries  covered  with  connective 
tissue  which  would  favor  the  formation  of  retention  cysts  in  the  Graafian 
follicles. 

Varieties  of  Cysts. 

They  may  be  simply  retention  cysts  formed  by  the  distension  of  Graafian 
follicles  with  serum  secreted  from  the  lining  of  these  follicles.  These  may 
be  simple  or  multiple,  and  may  remain  small  or  they  may  attain  enormous 
size.  The  largest  one  we  have  encountered  weighed  eighty-one  pounds  in 
a  woman  weighing  seventy  pounds  after  the  tumor  had  been  removed.  Cysts 
of  this  variety  have,  however,  been  reported  weighing  much  more. 

Again  the  epithelial  lining  of  the  Graafian  follicle  may  take  upon  itself 
an  abnormal  development,  forming  a  papilloma  or  a  carcinoma.  In  this 
event  the  cyst  contains  gelatinous,  viscid  fluid.  The  papillomatons  or  carci- 
nomatous  growths  may  perforate  the  cyst  wall  and  may  infect  the  peritoneum 
covering  the  intestines,  or  the  parietal  peritoneum,  and  then  the  free  peri- 
toneal cavity  may  contain  serous  or  gelatinous  fluid.  It  frequently  happens 


754  SURGERY    OF    THE    FEMALE    PELVIS 

that  this  growth  invades  the  surrounding  organs  and  gives  rise  to  complica- 
tions which  are  always  serious  in  character  ultimately. 

Occasionally  a  portion  of  the  ovary  is  located  in  the  broad  ligament 
and  may  in  such  location  give  rise  to  the  formation  of  a  cyst  known  as  a 
cyst  of  the  broad  ligament,  or  intra-ligamentous  cyst. 

A  tumor  may  consist  of  a  simple  retention  cyst  in  one  part,  and  a. 
papillomatous  cyst  in  the  remaining  portion. 

It  seems  likely  that  many  of  these  tumors  which  are  primarily  simple 
cysts,  later  on  degenerate  into  papillomatous  cysts,  and  these  in  turn  into 
carcinomatous  tumors. 
Diagnosis. 

Small  ovarian  cysts  are  diagnosed  by  bimanual  examination.  They  are 
recognized  as  more  or  less  spherical  masses  located  in  the  pelvis.  They  may 
lie  to  the  right  or  left,  behind  or  in  front,  or  above,  the  uterus.  Unless 
there  has  been  a  recent  pelvic  peritonitis  they  are  likely  to  be  movable  and 
can  be  separated  from  the  uterus.  If  the  abdominal  walls  are  not  very  thick 
fluctuation  can  usually  be  recognized.  Later  on  when  the  tumor  has  attained 
considerable  size  it  rises  in  the  pelvis  and  ultimately  is  forced  by  its  size 
to  occupy  the  abdominal  cavity  above  the  pelvis.  Fluctuation  can  now 
usually  be  established  across  the  abdomen.  The  tumor  displaces  the  intes- 
tines, consequently  percussion  over  its  most  prominent  portion  gives  rise  to 
a  dull  sound.  Above  and  to  either  side  there  is  resonance  because  of  the 
location  of  the  stomach  and  transverse  colon.  A  change  in  the  position  of 
the  patient  makes  no  change  in  the  percussion  sounds.  It  is  movable  unless 
strongly  adherent  on  account  of  peritonitis. 

Differential  Diagnosis. 

Early  in  the  disease  it  is  most  easily  confounded  with  pediculated  fibroid 
tumors  of  the  uterus.  The  latter  are,  however,  harder,  more  closely  con- 
nected with  the  uterus,  and  there  is  with  these  usually  a  history  of 
menorrhagia. 

Extra-uterine  pregnancy  may  be  mistaken  for  ovarian  cyst  early  in  its 
development,  but  the  absence  of  menstruation  is  likely  to  clear  up  such  a 
diagnosis. 

Pyosalpin.r  occasionally  simulates  an  adherent  ovarian  cyst,  but  its  loca- 
tion and  the  indications  of  a  more  or  less  septic  condition  usually  suffice  to 
determine. 

Later  on  abdominal  ascites  may  be  mistaken  for  an  ovarian  cyst.  An 
examination  of  the  urine  and  the  heart  will  establish  a  nephritic  or  cardiac 
cause  for  the  ascites.  In  the  physical  examination  it  will  be  found  that  the 
area  of  dullness  varies  with  the  position  of  the  patient  in  abdominal  ascites. 
unless  this  is  due  to  tuberculosis  with  the  presence  of  adhesions.  In  ascites 
the  tympany  is  usually  over  the  most  prominent  portion  of  the  abdomen, 
while  in  ovarian  cyst  the  opposite  condition  obtains,  there  being  an  area  of 
dullness  over  the  most  prominent  portion  and  tympany  over  the  epigastric 
and  lumbar  regions,  and  a  change  in  position  does  not  greatly  change  the 
percussion  sounds. 

It  frequently  occurs  that  the  intra-abdominal  organs  are  completely 
fixed  by  the  presence  of  adhesions  due  to  tubercular  peritonitis,  and  that 
the  intestines  and  omentum  form  a  wall  above,  and  the  pelvic  organs  to- 
gether with  the  sigmoid  flexure  of  the  colon  make  a  dam  below,  the  free 
ascitic  fluid,  causing  the  latter  to  become  encapsulated,  as  it  were,  between 


SURGERY    OF    THE    FEMALE    PELVIS  755 

the  abdominal  wall  in  front  and  these  two  barriers  above  and  below.  In 
such  cases  the  percussion  sounds  are  quite  as  constant  as  in  the  presence  of 
an  ovarian  cyst,  making  the  differential  diagnosis  from  the  physical  examina- 
tion virtually  impossible.  The  history  in  such  cases  will  show  that  the  intra- 
abdominal  accumulation  was  diffuse  during  the  early  part  of  the  disease, 
but  this  is  not  always  observed,  because  the  surgeon  is  not  consulted  until 
later.  There  is  also  an  evening  temperature  during  some  part  of  the  attack, 
but  this  again  is  not  always  observed,  and  when  the  patient  comes  under 
the  observation  of  the  surgeon  the  temperature  is  no  longer  abnormal. 

Obesity. 

Every  year  we  have  a  number  of  patients  sent  with  a  rather  acute,  cir- 
cumscribed obesity  or  lipomatosis  of  the  lower  portion  of  the  anterior  ab- 
dominal wall,  with  the  request  to  remove  an  abdominal  tumor.  Usually  a 
diagnosis  of  ovarian  cyst  has  been  made  on  account  of  the  presence  of 
pseudo-fluctuation  in  this  mass.  The  patients  are  usually  obese,  but  the 
general  condition  thereof  is  slight  compared  with  the  local,  and  unless  one's 
attention  has  been  directly  called  to  this  a  mistaken  diagnosis  is  most  natural. 
This  can  be  avoided  by  grasping  the  mass  laterally  and  lifting  it,  which 
will  show  it  to  be  entirely  in  the  tissues  of  the  abdominal  wall  and  not 
within  the  abdominal  cavity. 

Hydronephrosis. 

A  hydronephrosis  is  not  uncommonly  associated  with  movable  kidney, 
and  this  mobility  may  be  so  excessive  as  to  permit  the  kidney  to  visit  almost 
every  portion  of  the  abdominal  cavity,  and.  in  fact,  it  may  be  so  movable 
that  it  can  be  palpated  in  the  pelvis,  in  which  event  it  may  be  mistaken  for 
an  ovarian  cyst.  This  condition  is,  however,  uncommon.  It  usually  begins 
in  the  region  of  the  right  kidney ;  there  is  irregularity  in  the  size  of  the 
tumor,  and  the  decrease  in  its  size  is  associated  with  the  free  evacuation 
of  urine.  The  tumor  can  be  replaced  in  the  right  hypochondriac  region, 
and  when  thus  replaced  the  alteration  just  spoken  of  is  liable  to  occur,  be- 
cause this  disposes  of  the  acute  flexion  of  the  ureter.  There  are,  however, 
some  cases  in  which  it  will,  undoubtedly,  be  impossible  to  make  a  positive 
differential  diagnosis. 

Other  Simulating  Conditions. 

A  movable  spleen,  or  liver,  has  occasionally  been  mistaken  for  an 
ovarian  cyst.  This  is  also  true  of  cysts  of  the  pancreas.  Very  rarely  a  greatly 
distended  gall  bladder  may  be  exceedingly  movable,  in  fact,  quite  as  movable 
as  a  hydronephrosis,  and  in  such  an  instance  it  may  be  mistaken  for  an 
ovarian  cyst. 

These  errors  in  diagnosis  are  much  more  common  in  patients  with  thick 
abdominal  walls.  The  fluctuation  which  is  due  to  the  fat  in  the  abdominal 
wall  frequently  causes  an  error  of  diagnosis  by  transmitting  the  sensation 
of  fluctuation  to  solid  masses,  such  as  the  liver  or  the  spleen. 

Occasionally  an  ovarian  cyst  has  a  pedicle  sufficiently  long  to  permit 
the  tumor  to  be  carried  to  any  part  of  the  abdominal  cavity,  and  then  it  is 
likely  to  be  mistaken  for  a  tumor  connected  with  some  organ  in  whose  vicin- 
ity it  happens  to  be  first  discovered.  In  one  instance  we  encountered  a  carci- 
noma of  the  pylorus  as  large  as  a  fist,  which  could  be  moved  to  every  portion 
of  the  abdominal  cavity  and  which  was  first  discovered  in  the  right  inguinal 
region,  and  was  mistaken  for  a  cyst  of  the  ovary. 


756  SURGERY    OF    THE    FEMALE    PELVIS 

These  errors  are,  of  course,  quite  uncommon,  but  it  is  well  to  bear  in 
mind  the  possibility  of  their  occurrence. 

Ovarian  Cyst  with  Twisted  Pedicle. 

At  times  an  ovarian  cyst  with  a  long  pedicle  may  develop  to  a  consider- 
able size  without  being"  noticed,  until  by  some  chance  the  pedicle  becomes 
twisted  upon  itself  and  the  nutrition  of  the  cyst  thus  suddenly  interrupted. 
If  the  blood  vessels  are  entirely  occluded  the  occurrence  is  likely  to  be  accom- 
panied by  severe  pain,  which  may  give  rise  to  a  diagnosis  of  appendicitis, 
rupture  of  extra-uterine  pregnancy,  gall  stones,  or  renal  calculus  passing 
through  the  ureter.  The  abdominal  walls  are  usually  so  tense  after  such 
happening  that  it  is  practically  impossible  to  make  a  positive  diagnosis  with- 
out the  use  of  general  anesthesia,  unless  the  cyst  is  of  appreciable  size  and 
the  abdominal  walls  thin.  The  presence  of  a  tumor  will,  of  course,  clear 
up  the  differential  diagnosis,  with  the  exception  of  extra-uterine  pregnancy, 
which,  however,  is  characterized  by  the  presence  of  increasing  anemia,  and 
within  a  few  hours  after  the  beginning  of  the  attack  it  is  usually  possible 
to  palpate  the  coagulated  blood  in  the  cul-de-sac  of  Douglas  by  making  a 
vaginal  examination.  This  coagulated  blood  has  a  peculiar,  doughy  feeling, 
which,  when  once  detected,  will  be  readily  remembered. 

Distended  Urinary  Bladder. 

One  other  condition  has  been  mistaken  for  an  ovarian  cyst  more  fre- 
quently perhaps  than  any  other,  but  this  is  usually  the  result  of  careless- 
ness and  is  practically  always  cleared  up  before  an  attempt  is  made  to  re- 
move the  cyst  by  means  of  an  operation,  because  it  is  now  the  universal 
practice  to  catheterize  the  urinary  bladder  before  undertaking  an  abdominal 
section.  It  has  frequently  happened  that  a  distended  urinary  bladder  has 
been  regarded  as  an  ovarian  cyst,  but  the  passage  of  the  catheter  invariably 
clears  up  this  diagnosis ;  and  a  surgeon  who  has  once  experienced  this 
blunder  will  recognize  it  in  future  cases  without  the  slightest  difficulty. 

Impacted  feces  in  the  cecum  or  in  the  sigmoid  flexure  have  been  mis- 
judged for  ovarian  cyst.  The  free  catharsis  which  is  ordinarily  employed 
in  the  preliminary  treatment  of  these  cases  is  sure  to  clear  up  the  diagnosis. 

Dermoid  Cysts  of  the  Ovary. 

The  ovary  may  contain  a  certain  amount  of  epiblastic  tissue,  such  as  skin 
with  hair  follicles  or  mucous  membrane  with  embryonic  teeth,  or  these  may 
exist  in  connection  with  bone  or  connective  tissue  or  glandular  tissue.  These 
structures  may  remain  in  a  latent  state  for  a  long  period  of  time,  and  may 
then  begin  to  develop  into  what  are  technically  termed  dermoid  cysts  because 
of  the  hair  and  epithelium  and  teeth  which  they  are  likely  to  contain.  Such 
cysts  do  not  usually  develop  to  any  great  size.  They  usually  contain  more 
or  less  hard  tissue,  such  as  bone  or  cartilage,  and  are  consequently  prone  to 
give  rise  to  pain  on  account  of  pressure.  The  differential  diagnosis  of  these 
tumors  in  no  way  varies  from  that  in  ovarian  cysts,  and  their  treatment  cor- 
responds to  the  treatment  of  the  latter ;  consequently  it  will  not  be  necessary 
to  give  them  a  separate  discussion. 

Technique  for  the  Removal  of  Ovarian  Cysts. 

An  incision  is  made  in  the  median  line,  between  the  umbilicus  and  the 
pubis,  from  one  to  three  inches  in  length.  When  the  abdominal  cavity  has 
been  opened  the  cyst  will  present  as  a  bluish-white,  shining  surface.  If  the 


PLATE  CXXXIV. 

ABDOMINAL   INCISION   THROUGH   THE   LINEA   ALBA  BETWEEN   THE   UMBILICUS   AND  THE 

PUBIS. 

The  deep  silkworm  gut  sutures  being  in  place;  (a)  subcutaneous  fat:  (b)  deep 
fascia  composed  of  the  aponeurosis  of  the  internal  and  external  oblique  abdominal 
muscles;  (c)  the  rectus  abdominis  muscle;  (d;  the  peritoneum  and  transversalis 
fascia. 


PLATE  CXXXV. 

CLOSURE  Oi>  ^MEDIAN    AIUJO .\H.\AL   INCISION. 

Deep  silkworm  gut  sutures  extending  through  all  the  tissues  down  to  the  layer 
composed  of  the  peritoneum  and  transversalis  fascia  are  in  place,  hut  not  tied.  The 
peritoneum  and  transversalis  fascia  (d)  have  heen  untied  by  a  continuous  cat-gut 
suture,  care  being  taken  to  pass  these  sutures  over  the  silkworm  gut  sutures,  in 
order  that  this  layer  may  be  drawn  up  against  the  lower  surface  of  the  recti  muscles 
(c)  when  these  sutures  are  tied.  The  rectus  muscle  (c)  (c)  on  either  side  is  to  be 
united  to  its  fellow  with  a  few  interrupted  cat-gut  sutures,  and  the  deep  fascia  (b) 
(b)  is  to  be  united  with  a  continuous  cat-gut  suture.  The  fat  (a)  (a)  is  brought 
together  by  the  deep  silkworm  gut  sutures. 


SURGERY    OF    THE    FEMALE    PELVIS  761 

cyst  is  simple  it  will  be  regular  and  smooth  on  its  surface;  if  multiple,  one 
is  likely  to  observe  the  lobes  upon  its  external  surface. 

If  the  cyst  is  simple,  it  is  best  to  withdraw  the  fluid  from  its  cavity  by 
means  of  a  large-sized  trocar,  which  is  plunged  into  it,  an  assistant  pressing 
the  abdominal  walls  gently  against  the  surface  of  the  cyst  in  order  to  prevent 
the  accidental  escape  of  any  fluid  into  the  free  abdominal  cavity. 

The  fluid  contained  in  these  cysts  may  vary  in  color  from  a  perfectly 
clear,  limpid,  to  a  yellow  or  dark-colored  kind.  The  latter  color  is  usually 
the  result  of  a  hemorrhage  into  the  cavity  of  the  cyst  and  ordinarily  occurs 
in  cysts  which  have  been  subjected  to  some  form  of  traumatism,  such  as  a 
blow  upon  the  abdomen.  Cysts  which  have  previously  been  tapped  frequently 
contain  dark-colored  fluid  because  of  some  hemorrhage  which  has  taken 
place  into  the  cavity  through  the  wound  made  in  tapping.  Many  cysts  con- 
tain a  thick,  gelatinous  fluid,  which,  however,  is  present  usually  only  in  case 
the  lining  of  the  cyst  has  undergone  papillomatous  degeneration.  This  sub- 
stance may  be  so  thick  that  it  cannot  be  forced  through  a  trocar,  and  then 
the  abdominal  wound  will  have  to  be  enlarged  so  that  the  tumor  may  be 
removed  entire.  This  gelatinous  fluid  is  supposed  to  contain  cells  which 
may  give  rise  to  the  formation  of  secondary  growths  upon  the  peritoneal 
surfaces,  consequently  it  is  wise  not  to  permit  any  of  it  to  get  into  the  free 
peritoneal  cavity. 

The  clear  fluid  contained  in  ovarian  cysts  is  sterile  and  harmless,  and 
its  introduction  into  the  peritoneal  cavity  does  not  result  in  any  harm  to 
the  patient. 

After  the  removal  of  the  contents  to  a  sufficient  extent  to  cause  the  cyst 
wall  to  become  less  tense  the  same  may  be  grasped  in  forceps  and  drawn 
partly  out  through  the  abdominal  wound,  thus  protecting  the  free  peritoneal 
cavity  against  the  introduction  of  any  fluid.  After  the  cyst  has  become  en- 
tirely empty  it  may  be  withdrawn  through  the  abdominal  wound  and  its 
pedicle,  consisting  of  the  broad  ligament  and  the  Fallopian  tube,  may  be 
transfixed  and  ligated  with  cat-gut  or  fine  silk,  and  then  the  tumor  may  be 
cut  away,  care  being  taken  to  leave  a  sufficient  amount  of  pedicle  beyond 
the  ligature  to  prevent  slipping. 

Throughout  the  operation  there  should  be  as  little  unnecessary  dis- 
turbance of  the  tissues  as  possible. 

The  stump  which  is  left  after  cutting  away  the  tumor  may  be  covered 
with  peritoneum  by  means  of  a  few  cat-gut  stitches.  It  is  supposed  that 
this  will  prevent  the  forming  of  adhesions  with  the  intestines,  but  we  be- 
lieve that  after  an  aseptic  operation,  in  which  no  traumatism  is  inflicted  upon 
any  of  the  surrounding  tissues,  such  adhesions  practically  never  occur  even 
if  the  stump  is  not  covered  with  peritoneum;  while  they  do  occur,  notwith- 
standing this  covering,  provided  the  operation  is  septic  or  traumatism  has 
been  caused  to  the  surrounding  tissues. 

If  the  cyst  is  multiple,  composed  of  many  small  cysts,  the  trocar  may 
be  carried  from  one  to  the  other  of  these  without  being  withdrawn  from 
the  original  puncture,  provided  these  separate  cysts  are  large  enough  to 
make  such  practice  feasible.  If  the  cysts  are  too  small  it  is  better  to  enlarge 
the  abdominal  wound  sufficiently  to  permit  the  removal  of  the  tumor  in  toto. 
This  should  also  be  done  in  case  of  a  papillomatous  cyst,  or  a  cyst  containing 
fluid  too  thick  to  be  forced  out  through  the  trocar.  The  pedicle  of  such 
cysts  should  be  tied  and  the  tumor  removed  in  the  manner  described  for 
the  removal  of  simple  cysts. 


762  SURGERY    OF    THE    FEMALE    PELVIS 

It  is  wise  always  to  examine  the  opposite  ovary  at  the  time  of  operation, 
because  it  frequently  happens  that  the  second  ovary  contains  a  small  cyst 
which,  if  left  undisturbed,  will  enlarge  and  require  a  second  abdominal  sec- 
tion. Should  the  fellow  ovary  contain  cysts  of  any  size  in  a  patient  over 
forty  years  of  age,  it  is  wise  to  remove  the  entire  organ,  together  with  the 
Fallopian  tube,  according  to  the  method  described.  In  a  younger  patient 
it  is  usually  better  to  leave  at  least  one-fourth  or  one-half  of  the  ovary,  mak- 
ing a  conical  excision  of  the  diseased  portion  and  closing  the  surface  caused 
by  this  excision  by  means  of  fine  cat-gut  stitches.  This  will  ensure  the  nor- 
mal functions  of  the  ovary,  which  is  of  great  importance  to  a  young  patient. 

It  is  well  in  these  cases  to  examine  the  vermiform  appendix,  because 
remnants  of  disease  may  exist  in  this  organ  indicating  its  removal,  which 
can  be  accomplished  without  danger  to  the  patient,  according  to  the  methods 
described  in  the  section  devoted  to  appendicitis. 

The  abdominal  wound  is  closed  in  the  usual  manner,  care  being  taken 
to  unite  corresponding  layers. 

It  is  our  practice  to  split  the  inner  fascia  of  the  rectus.  abdominis  muscle 
on  each  side  and  to  unite  the  wound  by  inserting  deep  silk-worm  gut  sutures 
grasping  the  layers  down  to  the  transversalis  fascia,  and  then  applying  a 
separate  row  of  continuous  cat-gut  sutures  to  the  peritoneum  and  trans- 
versalis fascia,  uniting  the  recti  muscles  with  a  few  interrupted  cat-gut  su- 
tures ;  then  uniting  the  deep  fascia,  the  aponeurosis  of  the  external  and 
internal  oblique  muscles,  by  means  of  a  continuous  cat-gut  suture ;  then  tying 
the  silk-worm  gut  sutures  and  applying  a  row  of  coaptation  stitches  to  the 
skin,  as  illustrated  in  Plates  CXXXIV  and  CXXXV. 

Complications. 

The  most  common  complication  of  ovarian  cysts  affecting  the  method  of 
operation  is  the  presence  of  adhesions.  These  may  exist  between  the  ovarian 
cyst  and  any  one  or  more  of  the  intra-abdominal  organs.  The  most  common 
adhesions  are  to  the  omentum,  the  anterior  abdominal  wall,  and  to  the  intes- 
tines. It  does  not  matter  to  what  portion  an  ovarian  cyst  may  be  adherent, 
it  is  always  wise  to  expose  the  adhesion  before  an  attempt  is  made  to  dispose 
of  it,  because  although  it  may  occasionally  become  necessary  to  lengthen  the 
abdominal  incision  for  this  purpose,  still  this  is  of  slight  importance  as  com- 
pared to  the  benefit  the  patient  derives  from  having  this  portion  of  the  opera- 
tion performed  in  plain  sight.  These  adhesions  frequently  contain  very  large 
veins  and  their  injury  results  in  a  great  loss  of  blood,  which  is  in  itself 
undesirable  and  complicates  the  operation  by  covering  the  tissues  so  that 
they  can  be  recognized  with  less  ease.  It  is  usually  best  to  grasp  long 
adhesions  between  two  pairs  of  forceps,  to  cut  between  these,  and  to  ligate 
the  portion  which  is  not  connected  with  the  uterus,  and  then  drop  the  ad- 
hesions into  the  abdominal  cavity.  If  the  adhesion  is  to  the  intestine  or 
other  abdominal  organ  it  is  usually  possible  to  select  a  point  at  which  these 
tissues  can  readily  be  separated  from  each  other,  because  there  seems  to 
be  a  union  between  the  peritoneal  surfaces  which  is  not  firm  and  can  easily 
be  disturbed  if  one  succeeds  in  finding  the  point  of  cleavage.  It  is  well 
to  cover  at  once  with  peritoneum  any  abraded  surface  which  is  caused  by 
this  separation,  so  as  to  prevent  future  adhesions.  This  is  especially  im- 
portant if  the  abraded  surface  is  on  the  intestine.  If  this  precaution  is  not 
observed  a  perforation  may  readily  occur. 


SURGERY    OF    THE    FEMALE    PELVIS  763 

ABDOMINAL  HYSTERECTOMY. 

The  removal  of  the  uterus  is  in  itself  one  of  the  simplest  and  safest 
abdominal  operations  in  cases  in  which  the  condition  for  which  the  operation 
is  performed  is  not  connected  with  troublesome  complications.  The  success 
of  the  operation  depends  upon  the  appreciation  of  a  few  exceedingly  simple 
facts. 

In  this  operation,  as  in  every  other  abdominal  one,  the  first  principle  is, 
of  course,  the  prevention  of  infection.  This  may  be  accomplished  very 
easily,  as  the  only  source  of  infection  connected  with  the  operation  itself  is 
the  uterine  canal,  and  infection  from  this  may  easily  be  avoided  with  care. 

The  next  important  point  to  be  observed  is  the  control  of  hemorrhage. 
The  uterus  is  supplied  with  blood  by  two  small  arteries  on  each  side ;  the 
ovarian  approaching  it  through  the  upper  part  of  the  broad  ligament  on 
each  side,  and  the  uterine  artery  approaching  it  from  each  side  lower  down 
These  vessels  are  ordinarily  not  larger  than  a  good-sized  knitting  needle, 
and  are  consequently  of  no  importance,  provided  they  are  recognized  and 
carefully  ligated.  The  method  to  be  employed  for  the  control  of  hemorrhage 
will  depend  upon  the  choice  of  plan  for  removal ;  with  the  uterus,  the  Fallo- 
pian tubes  and  ovaries,  which  is  always  indicated  in  patients  over  forty 
years  of  age ;  or  the  removal  of  the  uterus  without  the  ovaries  and  tubes, 
indicated  in  younger  patients  in  whom  these  organs  in  themselves  are  not 
diseased. 

If  the  ovaries  and  tubes  are  to  be  removed  with  the  uterus,  two  pairs 
of  long-jawed,  strong  hemostatic  forceps  should  be  applied  to  the  broad  liga- 
ment, side  by  side,  just  externally  to  the  ovary.  They  should  extend  parallel 
to  each  other  with  a  space  of  one-half  to  three-fourths  of  an  inch  between 
them.  The  points  of  these  forceps  should  extend  to  the  body  of  the  uterus. 
This  should  be  done  alike  on  both  sides;  then  the  tissue  between  these  for- 
ceps is  severed  and  the  uterus,  ovaries  and  tubes,  grasped  by  the  two  pairs 
of  forceps  which  are  nearest  together,  can  be  elevated.  The  broad  ligament 
is  then  severed  farther  down  toward  the  cervix,  until  the  uterine  artery  is 
exposed.  This  is  grasped  by  a  separate  pair  of  forceps  on  each  side ;  then 
the  peritoneal  flap  is  cut  from  the  anterior  surface  of  the  uterus  and  dissected 
downwards  until  a  point  opposite  the  internal  os  is  approached.  The  uterus 
is  then  cut  away  by  means  of  a  conical  incision.  This  leaves  the  mucous 
membrane  lining  the  cervix  at  the  bottom  of  a  conical  space.  It  is  necessary 
to  exercise  great  care  in  cutting  down  upon  the  uterine  arteries  in  order  to 
approach  them  on  each  side  of  the  body  of  the  uterus  after  they  have  es- 
caped from  the  broad  ligaments.  If  this  precaution  is  not  taken  there  is 
danger  of  injuring  the  ureters,  which  pass  through  the  broad  ligament  near 
this  point. 

If  the  operation  is  performed  for  the  removal  of  a  myomatous  uterus 
great  care  must  be  taken  in  making  the  anterior  peritoneal  flap,  because  it 
frequently  happens  that  the  bladder  is  carried  a  considerable  distance  up 
over  the  anterior  surface  of  such  a  uterus,  and  if  care  is  not  exercised  in 
performing  this  part  of  the  operation  this  organ  is  likely  to  be  injured. 

It  is  necessary  to  be  careful  in  sponging  the  surface  of  the  uterine 
stump  not  to  carry  any  infectious  material  in  the  mucous  membrane  lining 
this  stump  to  other  portions  of  the  abdominal  cavity,  thus  causing  infection. 
For  the  same  reason  it  is  well  to  eliminate  this  remnant  of  the  canal  from 
the  operation  by  applying  cat-gut  stitches  to  unite  the  sides  of  the  conical 


764  SURGERY    OF    THE    FEMALE    PELVIS 

cavity  which  has  been  formed.  It  is  this  part  of  the  operation  which  should 
be  done  with  especial  care,  because  most  deaths  occurring-  after  abdominal 
hysterectomy  are  due  to  gangrene  of  the  uterine  stump,  which  results  from 
a  faulty  application  of  the  sutures.  During  the  early  practice  of  this  opera- 
tion surgeons  were  taught  to  fear  hemorrhage  following  hysterectomy,  and 
consequently  most  of  the  older  surgeons  acquired  the  habit  of  tying  the 
sutures  applied  to  the  stump  so  tightly  as  to  make  gangrene  thereof  a  very 
common  occurrence.  These  sutures,  and,  in  fact,  all  of  the  sutures  uniting 
the  surface  in  hysterectomy,  should  be  tied  just  sufficiently  firm  to  bring 
the  surfaces  together,  but  not  so  firm  as  to  cause  pressure  necrosis.  (The 
observation  of  this  precaution  in  our  own  practice  has  reduced  the  mortality 
in  abdominal  hysterectomy  to  almost  nothing.) 

During  the  past  few  years  we  have  abandoned  the  plan  of  suturing 
the  tissue  of  the  uterine  stump  and  have  simply  covered  this  stump  by  apply- 
ing fine  cat-gut  sutures  to  the  peritoneum,  thus  carefully  covering  the  raw 
surface  of  the  stump.  In  this  way  the  danger  from  pressure  necrosis  of 
the  part  is  entirely  eliminated  and  the  operation  becomes  as  safe  as  a  simple 
ovariotomy  or  appendectomy. 

The  broad  ligament  is  now  transfixed  with  a  cat-gut  or  fine  silk  stitch 
and  ligated  on  each  side,  care  being  taken  to  apply  this  ligature  so  that 
there  is  no  possibility  of  slipping.  Then  a  stitch  is  placed  around  the  uterine 
artery  on  each  side  and  tied  only  just  firm  enough  to  prevent  hemorrhage. 
Then  it  is  our  practice  to  apply  a  separate  ligature  to  the  end  of  the  uterine 
artery  grasped  by  the  forceps  on  each  side.  This  does  not  seem  necessary, 
but  we  continue  to  do  this  as  a  result  of  the  old  superstition  concerning  the 
likelihood  of  hemorrhage. 

The  entire  wound  should  now  be  sutured  from  side  to  side,  so  that 
..-very  portion  is  covered  with  peritoneum.  This  completes  the  very  simple 
operation ;  the  four  points  to  be  borne  in  mind  being: 

1.  The  avoidance  of  infection. 

2.  The  protection  of  the  ureters  and  bladder. 

3.  The  careful  control  of  hemorrhage. 

4.  And    (most  important  of  all)    the  prevention  of  gangrene  of  the 
stump  by  avoiding  too  firm  tying  of  sutures. 

In  case  it  is  desirable  not  to  remove  the  ovaries  and  tubes  the  operation 
is  done  in  the  same  manner,  with  the  exception  that  the  control  forceps 
are  applied  to  the  broad  ligament  directly  along  the  side  of  the  uterus,  leav- 
ing the  ovaries  and  tubes  to  the  outer  side  of  the  outer  forceps. 

SPLITTING  OF  THE  UTERUS. 

In  case  it  is  difficult  or  impossible  to  apply  the  forceps  to  the  broad  liga- 
ments because  of  the  presence  of  tumors  or  adhesions,  or  both,  conditions 
which  occur  occasionally,  the  operation  may  be  greatly  facilitated  by  inserting 
a  strong  pair  of  tenaculum  forceps  in  each  horn  of  the  uterus,  having  an 
assistant  make  quite  firm  traction  upon  these,  and  then  splitting  the  uterus 
longitudinally  down  to  a  point  opposite  the  internal  os.  The  tension  upon 
the  forceps  in  the  horns  of  the  uterus  prevents  hemorrhage  from  the  cut 
surfaces. 

Of  course,  the  same  precaution  must  be  used  against  injuring  the  blad- 
der on  the  anterior  surface  of  the  uterus,  if  it  extends  above  the  normal  posi- 
tion, that  was  mentioned  in  the  operation  just  described. 


PLATE  CXXXVI. 
ABDOMINAL  HYSTERECTOMY. 

a  uterus  ;  b  forceps  on  broad  ligament ;  c  Fallopian  tube ;  d  forceps  on  uter- 
ine side  of  broad  ligament;  e  forceps  on  ovarian  side  of  broad  ligament;  f  b 
der ;  /  round  ligament ;  o  ovary. 


PLATE  CXXXVTI. 
ABDOMINAL  HYSTERECTOMY. 

b  posterior  tlap  of  uterine  stump ;  c  anterior  flap  of  uterine  stump  ;  d  forceps 
on  uterine  artery;  c  forceps  on  broad  ligament;  /  bladder;  I  round  ligament;  j 
peritoneal  flap  for  covering  stump  of  uterus ;  g  colon. 


\ 


PLATE  CXXXVIIT. 
ABDOMINAL  HYSTERECTOMY. 

b  suture  closing  in  entire  surface  with  peritoneum;  c  Fallopian  tube;  /  blad- 
der; /  flaps  of  uterus;  g  colon;  o  ovary.  To  the  right  the  plate  shows  the  ovary 
and'tube  removed;  to  the  left  they  have  been  preserved. 


SURGERY    OF    THE    FEMALE    PELVIS  771 

When  the  internal  os  has  been  reached  a  slight  lateral  incision  is  made 
on  one  side  to  a  point  at  which  the  uterine  artery  is  exposed.  The  broad 
ligament,  together  with  the  uterine  artery,  is  then  grasped  from  below  by 
means  of  strong  forceps,  and  the  uterus  is  cut  away  to  the  inner  side  of 
these  forceps.  Another  pair  of  tenaculum  forceps  is  inserted  in  the  lower 
end  of  the  half  of  the  uterus  under  consideration,  and  tension  made  upon 
this  as  well  as  upon  the  tenaculum  forceps  in  the  horn  of  the  uterus  on 
this  side.  Care  must  be  taken  not  to  rela-x  upon  the  other  pair  of  tenaculum 
forceps  for  fear  of  causing  a  hemorrhage  upon  the  half  of  the  uterus  not 
immediately  under  consideration. 

After  the  lower  end  of  the  uterus  has  been  loosened  it  is  an  easy  matter 
to  grasp  the  remaining  vessels  in  the  broad  ligament  by  means  of  clamps, 
and  remove  the  half  of  the  uterus  together  with  the  tumor  it  may  contain.  • 
If  the  Fallopian  tube  or  ovary  are  also  in  a  pathological  condition  they  can 
readily  be  removed  with  this  portion  of  the  uterus.  The  same  steps  are 
taken  upon  the  opposite  side. 

After  the  uterus  has  been  removed  the  vessels  are  ligated  precisely  as 
in  the  operation  which  has  just  been  described.  The  stump  of  the  uterus 
is  disposed  of  in  the  same  manner,  and,  in  fact,  the  remainder  of  the  opera- 
tion is  in  no  way  different  from  that  which  has  just  been  outlined. 

Adhesions. 

If  there  are  adhesions  between  the  uterus,  or  the  ovaries  and  tubes,  and 
some  other  abdominal  organs,  these  must  be  loosened  with  great  care  and 
all  bleeding  points  carefully  ligated,  and  all  abraded  surfaces  carefully 
covered  with  peritoneum  by  means  of  Lembert  sutures.  Especial  pains  must 
be  taken  in  covering  large  abrasions  upon  the  small  intestine,  due  to  the 
necessity  of  loosening  extensive  adhesions.  Whenever  possible  it  is  wise 
to  make  transverse  closures  of  these  abraded  surfaces  for  fear  of  causing 
a  narrowing  of  the  small  intestine,  which,  however,  is  not  very  likely  to 
occur  because  of  the  elasticity  of  the  peritoneum.  If  any  abraded  surface 
in  the  pelvis  cannot  be  covered  with  peritoneum  it  is  wise  to  place  the  sigmoid 
flexure  upon  this  surface,  and,  if  necessary,  to  fasten  it  by  a  few  fine  cat-gut 
stitches.  The  abdominal  wound  is  closed  in  the  usual  manner. 

MYOMECTOMY. 

Generally  speaking  it  is  proper  to  make  a  hysterectomy  for  any  cases 
of  fibroid  tumors  of  the  uterus  in  patients  of  forty  years  of  age  or  over,  in 
whom  this  operation  seems  to  require  the  least  amount  of  traumatism.  In 
younger  patients,  whenever  possible,  the  excision  of  fibroid  tumors  of  the 
uterus,  without  the  removal  of  the  uterus  itself,  should  be  practised,  even 
though  the  operation  be  connected  with  greater  difficulty  and  with  greater 
traumatism.  It  is  surprising  how  easily  fibroid  tumors  may  be  enucleated 
from  the  uterus  even  when  deeply-seated,  and  if  traction  is  made  upon  the 
organ  this  operation  is  not  connected  with  much  hemorrhage. 

If  the  tumor  is  in  the  superior  portion  of  the  uterus  the  transverse 
incision  should  be  made  and  the  tumor  enucleated.  Here  again  the  same 
principle  should  be  applied  that  has  been  mentioned  in  connection  with  the 
closure  of  the  stump  in  abdominal  hysterectomy.  The  space  from  which  the 
tumor  has  been  removed  should  be  closed  by  means  of  fine  cat-gut  sutures 
which  are  tied  just  firmly  enough  to  bring  the  surfaces  together,  but  not 
sufficiently  'firm  to  cause  pressure  necrosis.  As  many  rows  of  these  sutures 


772  SURGERY    OF    THE    FEMALE    PELVIS 

as  are  required  to  close  the  entire  cavity  should  be  employed ;  their  number  is 
of  no  special  importance. 

When  the  outer  wound  in  the  surface  of  the  uterus  is  reached  it  is 
important  to  extend  the  suturing  a  little  beyond  each  end  of  the  wound, 
because  this  will  overcome  the  troublesome  oozing  which  frequently  occurs 
from  the  very  ends  of  the  incision  in  case  this  precaution  is  not  taken. 

If  the  uterine  cavity  is  opened  during  the  operation,  it  should  be  care- 
fully sponged  or  curetted  and  a  folded  piece  of  rubber  protective  tissue 
passed  through  the  uterine  canal  into  the  vagina  for  the  purpose  of  drainage. 
In  this  case  the  first  row  of  sutures  should  pass  down  to,  but  not  through,  the 
mucous  membrane,  for  fear  of  infecting  the  deeper  tissues  in  the  uterus. 
The  danger  of  infection  from  the  uterine  canal  in  these  cases  has  been 
greatly  over-estimated,  and  we  believe  that  in  cases  in  which  there  has 
apparently  been  such  an  infection  it  has  resulted  from  the  fact  that  the 
sutures  which  were  applied  for  the  purpose  of  protecting  the  wound  in  the 
uterus  were  tied  too  firmly  and  gave  rise  to  pressure  necrosis.  In  case  a 
large  fibroid  has  developed  in  the  broad  ligament,  so  that  after  its  removal 
there  remains  a  large  raw  surface,  this  should  be  covered  with  peritoneum, 
but  if  the  uterine  cavity  has  been  opened  during  the  operation,  or  if  the 
rectum  or  the  sigmoid  flexure  have  been  disturbed,  it  is  best  to  insert  a  small 
glass  drain  or  a  cigarette  drain  into  the  angle  of  the  broad  ligament  next 
to  the  uterus  and  to  permit  this  to  pass  out  of  the  lower  angle  of  the  ab- 
dominal wound.  It  may  be  removed  in  two  to  five  days. 

PYOSALPINX. 

Clinical  Example. 

This  case  is  typical  of  the  disease  under  consideration.  The  patient  is 
twenty-three  years  of  age,  married  fourteen  months,  and  gives  the  following 
history : 

She  suffered  from  mild  attacks  of  all  the  contagious  diseases  of  child- 
hood, but  experienced  no  unfavorable  after-effects.  Menstruation  began  at 
the  age  of  fourteen,  was  regular  and  painless,  and  the  patient's  health  was 
excellent  until  a  short  time  after  her  marriage,  when  she  suddenly  experi- 
enced severe  pain  in  the  lower  portion  of  her  abdomen.  She  had  previously 
observed  the  presence  of  leucorrhea  and  a  mild  attack  of  cystitis,  to  which 
she  gave  no  attention.  After  remaining  quiet  for  two  clays,  taking  hot 
douches  and  a  cathartic  and  applying  heat  to  the  abdomen,  the  pain  subsided 
and  she  was  able  to  be  up  and  about,  but  since  that  time  she  has  never  felt 
perfectly  strong  and  well.  Her  next  menstrual  period  was  characterized  by 
severe  pain,  lasting  for  two  days  and  leaving  her  slightly  worse  than  before. 
She  felt  feverish  during  the  entire  period  of  menstruation.  She  has  con- 
tinually grown  worse,  suffering  from  severe  pain  every  few  days,  and  during 
each  successive  menstrual  period  having  an  attack  more  severe  than  the  pre- 
ceding. During  the  past  two  months  she  has  scarcely  recovered  from  the 
effects  of  one  attack  before  experiencing  the  next.  At  the  time  of  her  mar- 
riage she  was  strong  and  vigorous  and  in  every  way  in  excellent  health. 
Present  Condition. 

Anemic,  somewhat  emaciated,  having  lost  twenty  pounds  during  the  past 
year.  Her  appearance  indicates  that  she  has  suffered  severely.  Skin  is 
rough  and  her  color  is  bad. 


SURGERY    OF    THE    FEMALE    PELVIS  773 

Physical  Examination. 

All  organs,  with  the  exception  of  the  pelvic,  are  normal.  A  pelvic  ex- 
amination reveals  the  presence  of  severe  induration  throughout  the  pelvic 
floor.  In  the  left  broad  ligament  there  is  a  mass  as  large  as  a  man's  fist.  The 
right  broad  ligament  contains  a  mass  about  one-half  as  large.  The  cervix 
of  the  uterus  is  enlarged  to  twice  the  normal  size ;  it  is  hard  and  edematous. 
Bimanual  examination  seems  to  reveal  a  slight  amount  of  fluctuation  in  the 
left  side. 

Upon  rectal  examination  there  is  found  an  indurated  area  opposite  the 
cul-de-sac  of  Douglas,  which  renders  this  portion  of  the  bowel  quite  rigid. 
The  patient  complains  severely  of  pain  during  both  the  rectal  and  vaginal 
examinations.  Upon  bimanual  examination  the  abdominal  muscles  contract 
to  protect  the  inflamed  tissues  underneath. 

Diagnosis. 

The  history,  as  well  as  the  physical  investigation,  indicate  the  presence 
of  an  infection  involving  the  uterus,  Fallopian  tubes  and  pelvic  peritoneum. 
This  is  undoubtedly  gonorrheal  in  origin,  because  of  the  time  of  its  occur- 
rence, the  presence  of  leucorrhea  and  cystitis,  and  the  physical  evidences. 

Upon  inquiry  we  have  determined  that  the  husband  suffered  from  an 
acute  specific  urethritis  two  years  ago,  from  which  he  recovered  after  four 
months,  but  that  he  occasionally  noticed  a  slight  amount  of  secretion  after 
some  indiscretion  in  diet  or  over-exertion.  About  one  week  after  his  mar- 
riage be  noticed  a  slight  recurrence  of  this  condition,  which,  however,  dis- 
appeared after  a  few  days. 

It  is  likely  that  the  infection  advanced  slowly  through  the  uterine  canal 
and  through  the  Fallopian  tubes  and  that  the  fimbriated  extremities  of  the 
latter  organs  have  become  adherent  to  the  ovaries  and  thus  become  occluded, 
and  that  pus  has  accumulated  in  the  distended  Fallopian  tubes. 

The  patient  has  received  local  treatment  almost  constantly  since  the  be- 
ginning of  her  illness,  by  means  of  hot  douches,  the  application  of  tincture 
of  iodine  and  nitrate  of  silver  to  the  uterine  canal  and  the  cervix,  and  by  the 
application  of  vaginal  pads  saturated  with  glycerine  and  ichthyol ;  but  none 
of  these  remedies  has  been  of  any  permanent  benefit. 

Treatment. 

During  the  early  part  of  the  disease  it  is  best  to  make  use  of  non-surgi- 
cal means. 

ist.  Because  many  severe  infections  of  this  form  recover  completely 
under  this  treatment  and  later  go  through  normal  pregnancies  provided  rein- 
fection is  avoided. 

2nd.  Because  surgical  treatment  is  exceedingly  dangerous  during  the 
early  portion  of  the  disease,  while  it  is  quite  safe  later  on. 

3rd.  The  patient  is  not  exposed  to  any  risk  because  of  the  postpone- 
ment of  operation,  provided  the  internal  treatment  is  carried  out  properly 
and  rest  in  bed  is  insisted  upon. 

The  infection  affects  a  relatively  small  and  a  safe  portion  of  the  perito- 
neal cavity — the  pelvic  portion.  If  it  is  confined  to  this  region  the  worst 
possible  consequence  will  be  a  circumscribed  abscess  which,  from  its  loca- 
tion, may  either  become  absorbed,  or  remain  encapsulated,  or  it  may  rupture 
into  the  rectum,  the  bladder  or  the  vagina.  If  undisturbed  the  rupture  will 
practically  always  take  place  into  the  rectum  if  it  occurs  at  all,  which  is,  of 
course,  the  most  favorable  direction. 


774  SURGERY    OF    THE    FEMALE    PELVIS 

The  Circumscribed  Infection. 

Anatomically  the  arrangement  is  most  perfect  for  the  development  of 
circumscribed  abscesses. 

If  the  infection  advances  slowly  the  fimbriated  extremities  of  the  Fallo- 
pian tubes  will  become  adherent  to  the  ovaries  or  to  the  floor  of  the  pelvis, 
and  then  the  infection  will  be  confined  to  one  or  to  both  tubes.  It  may  re- 
main in  this  position,  dilating  the  tubes  until  they  attain  a  considerable  size, 
or  they  may  become  distended  beyond  their  capacity  and  rupture  and  infect 
the  surrounding  tissues.  In  this  event  adhesions  have  usually  formed  be- 
fore the  rupture  takes  place.  These  most  commonly  exist  between  the  tube 
and  the  omentum  or  cecum,  or  sigmoid  flexure  of  the  colon,  or  some  loop  of 
the  small  intestines,  or  several  or  all  of  these.  It  is  very  seldom  that  an  ab- 
scess of  this  kind  ruptures  into  the  free  peritoneal  cavity  except  as  the  re- 
sult of  a  severe  strain  or  a  traumatism. 

With  a  circumscribed  infection  the  conditions  are  very  similar  to  those 
'described  with  the  infection  due  to  perforative  or  gangrenous  appendicitis, 
and  consequently  the  early  treatment  should  have  the  same  end  in  view  as 
has  the  non-surgical  treatment  of  acute  appendicitis,  namely,  the  confinement 
of  the  infection  to  the  vicinity  of  the  tissues  originally  involved. 

The  physiological  elimination  of  the  infected  area  in  the  condition  under 
consideration  is  almost  perfect  because  the  omentum  will  apply  itself  to  the 
surface  of  the  tube,  the  sigmoid  flexure  will  apply  itself  above  and  to  the 
left,  and  the  cecum  and  appendix  to  the  right.  If  there  is  still  a  small  area 
left  it  will  be  occupied  by  some  portion  of  the  small  intestine,  and  as  all  of 
the  tissues  which  have  been  mentioned,  except  the  small  intestine,  are  rela- 
tively fixed,  the  infection  is  likely  to  remain  circumscribed  unless  it  is  car- 
ried by  the  small  intestine  from  its  original  area  to  other  portions  of  the  peri- 
toneal cavity.  This  can  be  prevented  by  inhibiting  peristaltic  motion,  which, 
as  has  been  shown  before,  may  be  accomplished  by  the  prohibition  of  all  food 
and  cathartics  by  mouth  and,  if  necessary,  by  the  addition  of  the  use  of 
opium.  If  the  stomach  contains  food  or  mucus  this  should  be  removed  by 
gastric  lavage. 

It  should  be  remembered  that  where  neither  food  nor  cathartics  are 
given  by  mouth,  opiates  may  be  administered  either  by  enemata  or  hypo- 
dermatically  with  safety  to  the  patient. 

Large  hot  vaginal  douches  frequently  administered  are  a  source  of 
great  comfort  and  are  of  undoubted  benefit  to  these  patients.  The  douches 
should  be  given  as  hot  as  they  can  be  borne.  The  patient  may  be  nour- 
ished by  the  use  of  nutritive  enemata,  which  have  been  described  herein 
before. 

There  is  an  important  advantage  in  first  treating  all  cases  of  this  class 
by  the  method  just  described,  aside  from  those  mentioned  early  in  .the  con- 
sideration of  this  subject,  owing  to  the  fact  that  the  virulence  of  the  micro- 
organisms causing  this  infection  will  be  very  greatly  reduced  if  the  infection 
is  compelled  to  remain  circumscribed ;  in  other  words,  we  make  use  of  the 
principle  of  rest  in  the  treatment  of  this  infectious  disease  the  same  as  we 
do  in  the  treatment  of  like  conditions  in  other  parts  of  the  body.  If  this 
state  of  rest  is  continued  for  a  time  the  infection  becomes  so  thoroughly  cir- 
cumscribed that  the  pus  itself  will  ultimately  destroy  all  of  the  micro-or- 
ganisms which  it  contains,  and  when  examined  will  be  found  perfectly 
sterile. 


SURGERY    OF    THE    FEMALE    PELVIS  775 

An  operation  performed  after  the  pus  has  acquired  this  condition  of 
sterility  is  of  course  relatively  very  much  safer  than  if  done  while  the  pus 
is  still  full  of  living  pathogenic  micro-organisms.  It  is  likely  that  in  many 
cases  in  which  it  was  supposed  that  a  re-infection  took  place  from  the  pus 
that  existed  in  a  circumscribed  abscess,  there  was  in  fact  a  re-infection 
through  the  uterus.  The  occurrence  of  such  re-infection  should,  of  course, 
be  carefully  guarded  against. 

Although  a  large  majority  of  cases  in  which  there  is  but  a  single  infec- 
tion of  the  Fallopian  tubes  will  recover  fully,  or  to  such  an  extent  that  it  is 
impossible  to  determine  the  presence  of  any  pathological  condition  by  physi- 
cal examination,  there  will  always  be  many  who  have  either  had  repeated 
infections  or  have  not  recovered  fully  from  a  single  infection,  and  these 
cases  can  be  relieved  permanently  only  by  a  surgical  operation. 

Operative  Technique. 

The  operative  treatment  must  be  planned  so  that  none  of  the  clean 
portions  of  the  abdominal  cavity  become  infected  during  operation,  so  that  all 
of  the  disease  is  removed,  and  so  there  will  be  no  serious  secondary  condi- 
tions developed  as  the  result  of  the  operation. 

To  prevent  the  infection  of  portions  of  the  peritoneal  cavity  not  in- 
volved, it  is  wise  to  make  the  abdominal  incision  sufficiently  long  to  enable 
the  surgeon  to  perform  the  necessary  manipulations  in  sight.  In  severe 
cases  it  is  usually  best  to  make  the  incision  from  a  point  an  inch  below 
the  umbilicus  to  the  pubis.  In  mild  cases  it  may  be  considerably  shorter.  In 
unusually  severe  ones  it  is  often  best  to  carry  the  incision  around  the  umbili- 
cus to  the  left  and  a  convenient  distance  above  the  same. 

The  operation  can  be  greatly  facilitated  by  placing  the  patient  in  the 
Trendelenburg  position,  by  elevating  the  foot  of  the  table  so  that  the  pa- 
tient's body  rests  at  an  angle  of  about  forty  degrees.  This  causes  the  in- 
testines to  withdraw  into  the  upper  portions  of  the  peritoneal  cavity,  or  if 
they  do  not  take  this  position  by  their  own  weight,  the  object  may  be  ac- 
complished by  pushing  the  intestine  upwards  by  means  of  a  large,  moist, 
sterile,  gauze  compress.  The  intestines  should  be  carefully  tamponed  away 
from  the  seat  of  the  operation,  as  thus  they  will  not  be  exposed  to  infection 
during  the  operation,  nor  to  the  irritating  influence  of  the  air. 

The  entire  operation  can  now  be  done  without  manipulating  anything 
outside  of  the  pelvis,  and  this  portion  of  the  peritoneal  cavity  is  the  least 
sensitive  and  its  manipulation  is  accompanied  by  the  slightest  amount  of 
shock.  This  is  a  fact  of  very  great  importance,  and  if  borne  in  mind  the  pa- 
tient's suffering  may  be  reduced  greatly  and  her  chances  of  recovery  much 
improved.  The  further  steps  of  the  operation  will  depend  upon  the  extent 
of  the  infection  and  upon  the  parts  involved,  as  well  as  upon  the  number 
and  firmness  of  adhesions. 

If  the  Fallopian  tubes  alone  are  concerned,  forming  sausage-shaped 
bags  of  pus,  the  operation  will  be  identical  with  that  described  for  the  re- 
moval of  ovarian  cysts.  The  broad  ligament  will  be  ligated  below  the  mass 
and  a  second  ligature  placed  around  the  Fallopian  tube  near  the  uterus  and 
the  mass  cut  away,  leaving  a  sufficient  amount  of  tissue  beyond  the  ligature 
to  prevent  slipping.  It  is  well  to  place  a  pair  of  forceps  upon  the  Fallopian 
tube  beyond  the  point  at  which  this  is  cut  away  in  order  to  prevent  any 
leakage  from  the  cut. 

Many  authorities  prefer  to  excise  a  conical  portion  of  the  uterus  to- 


7/6  SURGERY    OF    THE    FEMALE    PELVIS 

gether  with  the  end  of  the  Fallopian  tube,  and  to  close  this  by  means  of 
sutures.  Theoretically  such  method  seems  preferable,  but  practically  there 
is  no  difference  between  the  two. 

If  the  adhesions  are  extensive  it  is  often  much  easier  to  place  two  pairs 
of  forceps  upon  the  Fallopian  tube  at  its  point  of  entrance  into  the  uterus. 
The  forceps  should  be  placed  parallel  to  each  other ;  then  the  tube  cut  away 
between  these,  which  opens  the  space  between  the  upper  and  lower  fold  of 
the  broad  ligament.  By  applying  forceps  successively  upon  the  broad  liga- 
ment from  within  outward,  and  cutting  between,  it  is  usually  possible  to 
enucleate  the  pus  tube  without  the  danger  of  rupturing  it.  In  many  cases 
the  uterus  itself  seems  so  thoroughly  infected  that  it  may  be  best  to  re- 
move it  together  with  the  tubes  and  ovaries.  Then  the  operation  de- 
scribed for  the  removal  of  the  uterus  containing  fibroid  tumors 
may  be  employed,  great  care  being  taken,  of  course,  to  prevent  a  rupture  of 
the  abscess.  It  is  in  such  cases  that  the  method  of  splitting  the  uterus 
longitudinally  is  often  of  especially  great  value.  The  remaining  steps  are 
the  same  as  those  which  have  been  already  pointed  out. 

Here  again  it  is  particularly  important  to  exercise  care  in  inspecting  the 
surfaces  of  the  small  intestines  which  have  been  adherent  to  the  ovaries  or 
tubes,  or  to  the  infected  uterus,  as  in  loosening  these  adhesions  it  sometimes 
happens  that  a  loop  of  intestine  is  perforated,  and  unless  such  perforation  is 
carefully  closed  and  the  surface  covered  with  peritoneum  a  fecal  fistula  is 
apt  to  occur  and  the  intestinal  contents  may  cause  an  infection  of  the  perito- 
neum, giving  rise  to  a  septic  peritonitis  from  which  the  patient  may  die. 

After  all  of  the  diseased  tissue  has  been  removed  it  is  wise  to  cover 
the  abraded  surfaces,  as  far  as  possible,  with  portions  of  the  surrounding 
healthy  peritoneum.  If  this  cannot  be  done  the  sigmoid  flexure  should  be 
brought  down  and  placed  across  this  portion  of  the  pelvis,  and  if  there  is 
doubt  about  this  remaining  in  position  it  is  well  to  fasten  it  by  means  of  a 
few  cat-gut  stitches.  The  omentum  should  also  be  brought  down  to  this 
surface.  If  the  operation  has  been  accomplished  without  causing  a  rupture 
of  the  abscess  the  surface  should  be  sponged  perfectly  dry,  the  gauze  tam- 
pons placed  for  the  protection  of  the  surrounding  intestines  should  be  re- 
moved, and  it  is  well  to  bring  the  omentum  down  from  the  small  intestines 
so  that  these  do  not  come  in  contact  with  the  field  of  operation,  because  of 
the  danger  of  distribution  of  infectious  material  by  peristaltic  motion. 

If  there  is  any  doubt  about  the  aseptic  state  of  the  field  of  operation 
it  is  always  best  to  apply  some  form  of  drainage.  We  have  found  a  curved 
glass  drainage  tube,  half  an  inch  in  diameter,  placed  within  a  strand  of 
iodoform  gauze  behind  the  stump  of  the  uterus  in  the  cul-de-sac  of  Douglas, 
and  permitted  to  protrude  through  the  lower  angle  of  the  wound,  most  satis- 
factory. This  tube  can  usually  be  removed  on  the  second  day,  and  the  gauze 
surrounding  it  two  days  later,  permitting  the  abdominal  wound  tc  close  per- 
fectly without  danger  of  the  formation  of  ventral  hernia. 

If  there  has  been  a  severe  infection  it  may  be  necessary  to  leave  the  tube 
in  place  for  a  longer  period  of  time. 

The  abdominal  wound  is  closed  down  to  the  drainage  tube  in  the  usual 
manner.  In  many  cases  it  is  simpler  and  better  to  puncture  the  vault  of  the 
vagina  with  a  pair  of  blunt  pointed  scissors  or  forceps  and  drain  the  infected 
area  directly  into  the  vagina  by  means  of  gauze  or  cigarette  drains,  or  by 
combining  these  with  rubber  drainage  tubes.  In  some  verv  extensive  case? 


SURGERY    OF    THE    FEMALE    PELVIS  777 

we  have  combined  this  method  with  that  just  described,  draining  both 
through  the  vagina  and  through  the  abdominal  wound. 

These  points  then  are  of  marked  importance : 

ist.  Banking  away  of  the  non-infected  contents  of  the  abdominal 
cavity. 

2nd.     Manipulation  of  only  the  structures  contained  in  the  pelvis. 

3rd.     Care  to  prevent  perforation  of  the  intestine. 

4th.  Covering  of  all  raw  surfaces  either  with  peritoneum  or  with  the 
sigmoid  flexure  or  omentum,  or  both. 

5th.  Drainage  in  cases  in  which  the  surgeon  is  not  positive  that  the 
field  is  aseptic,  preferably  into  the  vagina. 

After-treatment. 

If  these  patients  bear  the  administration  of  small,  frequently -repeated 
draughts  of  hot  water  well,  such  should  be  given.  If  this  causes  nausea  or 
vomiting  it  is  best  simply  to  have  the  patient's  mouth  rinsed  with  hot  or  cold 
water  and  not  give  anything  by  mouth  for  two  days.  At  the  end  of  such 
time  beef-tea  or  one  of  the  various  concentrated  predigested  foods  may  be 
given  every  two  hours  in  small  doses.  After  two  days  these  patients  usually 
bear  hot  water  well.  Rectal  feeding  is  generally  somewhat  dangerous  be- 
cause of  the  congestion  which  followrs  an  extensive  operation  in  the  pelvis. 
The  alimentary  canal  should  be  perfectly  empty  before  the  operation,  a? 
a  result  of  the  administration  of  two  ounces  of  castor  oil  on  the  previous 
day.  If  no  further  food  is  given  by  mouth  morphine  may  safely  be  admin- 
istered hypodermatically  if  necessary,  to  quiet  the  pain.  Of  course,  in  cases 
which,  for  any  reason,  must  be  operated  during  the  acute  attack  no  cathartic 
should  be  given  before  the  operation,  for  fear  of  causing  the  septic  material 
to  be  carried  from  its  circumscribed  location  to  distant  portions  of  the  ab- 
dominal cavity  by  the  production  of  peristalsis  resulting  from  the  cathartic. 

If  for  any  reason  it  seems  objectionable  to  perform  an  abdominal  sec- 
tion in  these  cases,  the  uterus,  ovaries  and  tubes  may  be  removed  by  the  vag- 
inal route,  to  be  described  later.  The  objection  to  this  route  lies  in  the  fact 
that  the  conditions  cannot  be  so  perfectly  determined  and  one  frequently  re- 
moves organs  which  might  be  saved  if  the  abdominal  operation  were  chosen. 
It  also  happens  frequently  that  a  diseased  vermiform  appendix  is  overlooked. 

In  the  criminal  classes  we  believe  this  operation  is  indicated  much  more 
commonly  than  among  other  patients,  because  re-infection  is  almost  certain 
to  occur  if  the  uterus  is  not  removed  together  with  the  other  infected  organs. 

In  all  of  these  patients  it  is  extremely  important  to  leave  at  least  a  por- 
tion of  one  ovary  so  long  as  the  patient  has  not  passed  the  menopause,  as 
if  both  ovaries  are  completely  removed  in  young  women  the  patient  is  likely 
to  suffer  from  severe  nervous  disturbances.  These  may  fortunately  be 
avoided  by  leaving  a  portion  of  one  ovary. 

\ 

TRANSPLANTATION  OF  OVARIES. 

In  many  of  these  cases  in  which  both  ovaries  have  been  removed  at  a 
previous  operation,  great  benefit  may  be  secured  by  transplanting  a  fairly 
healthy  ovary  by  the  following  method  :  It  is  best  to  select  for  a  source  an 
ovary  which  must  be  removed  because  of  prolapse  in  a  case  in  which  the 
fellow  ovary  is  quite  normal  and  in  which  it  seems  unlikely  that  any  opera- 
tion short  of  removal  would  result  in  the  relief  of  the  patient.  This  ovary 


778  SURGERY    OF    THE    FEMALE    PELVIS 

may  be  preserved  in  sterile  normal  salt  solution  for  several  days  or  weeks 
and  may  then  be  transplanted,  but  it  is  probably  better  to  make  the  trans- 
plantation directly  from  one  patient  to  the  other. 

Technique  of  Operation. 

An  incision  ten  cm.  long  is  made  over  the  middle  of  the  rectus  abdominis 
muscle.  The  aponeurosis  is  split  and  also  the  muscle.  Its  posterior  sur- 
face is  separated  from  the  transversalis  fascia.  The  ovary  is  laid  open  by 
means  of  a  longitudinal  incision.  The  ovary  is  then  placed  in  the  pocket 
between  the  muscle  and  the  transversalis  fascia,  with  the  raw  surface  caused 
by  splitting  directed  toward  the  muscle.  It  is  held  in  place  by  a  few  fine  cat- 
gut sutures,  then  the  split  in  the  muscle  is  sutured,  and  then  the  aponeurosis 
and  skin  wounds  are  closed  and  an  ordinary  dressing  applied.  If  the  uterus 
has  not  been  removed  and  the  patient  is  young,  menstruation  may  be  re- 
established and  the  nervous  disturbances  due  to  the  artificial  menopause  are 
likely  to  disappear. 

It  is  of  course  important  to  choose  an  ovary  from  a  patient  who  is  free 
from  syphilis  and  tuberculosis.  It  may  be  well  to  test  the  donor  with  one 
of  the  various  tests  for  tuberculosis  and  for  syphilis  in  order  to  be  quite  safe. 

ABDOMINAL  VS.  VAGINAL    HYSTERECTOMY. 

During  the  past  few  years  there  has  been  much  difference  of  opinion 
regarding  the  advisability  of  treating  the  various  surgical  diseases  of  the 
pelvic  cavity  through  an  abdominal  incision,  or  through  a  vaginal  incision ; 
the  general  surgeon,  as  a  rule,  being  more  familiar  with  the  abdominal 
route  than  with  the  vaginal,  has  usually  supported  the  former,  while  the 
gynecologist  has  more  commonly  advised  the  vaginal  route  for  the  relief 
of  all  conditions  that  could  be  accomplished  through  a  vaginal  incision.  The 
abdominal  route  has  undoubtedly  the  advantage  of  enabling  the  surgeon  to 
expose  the  pelvic  cavity  freely,  especially  since  these  operations  are  per- 
formed with  the  patient  in  the  Trendelenburg  position,  by  means  of  which 
the  intestines  can  easily  be  removed  from  the  pelvis,  leaving  only  the  uterus 
and  adnexae,  the  bladder  and  the  rectum  in  this  cavity.  This  route  also 
permits  the  surgeon  to  examine  the  appendix,  for  disease  frequently  the 
concomitant  of  other  pelvic  troubles ;  it  also  enables  him  to  examine  the 
gall  bladder  and  to  dispose  of  adhesions  between  the  omentum  or  the  in- 
testines and  the  pelvic  organs.  The  vaginal  route  has  the  advantage  of 
being  safer  in  the  hands  of  a  surgeon  who  is  familiar  with  this  class  of 
operations,  the  mortality  in  all  forms  of  operations  performed  by  this  route 
being  exceedingly  low. 

There  is  the  further  advantage  in  the  fact  that  no  external  scar  is  pro- 
duced by  this  avenue  which  is  of  importance  to  some  patients  who  are 
exceedingly  sensitive.  In  order  to  overcome  this  objection  Pfannenstiel  in- 
troduced the  transverse  incision  for  abdominal  section,  made  in  the  area 
covered  by  the  pubic  hair  which  will  later  hide  the  scar  completely. 

VAGINAL  HYSTERECTOMY. 

This  operation  is  indicated  in  carcinoma  of  the  uterus  so  long  as  this 
organ  is  movable  and  there  is  no  positive  evidence  of  the  invasion  of  any 
of  the  surrounding  tissues,  and  no  infection  of  the  inguinal  lymphatic  glands. 


PLATE  CXXXIX. 
VAGINAL  HYSTERECTOMY. 

The  vaginal  orifice  is  held  open  by  means  of  specula  (e)  (d).  The  cervix  (a) 
is  loosened  from  fts  vaginal  attachment  by  an  elliptical  incision.  The  uterine  arteries 
are  picked  up  with  a  cat-gut  suture  (b)  and  tied.  Sutures  are  inserted  on  either 
side  (c)  for  the  closure  of  the  wound,  but  left  untied  until  the  uterus  has  been 
removed. 


PLATE  CXL. 

VAGINAL  HYSTERECTOMY. 

The  orifice  is  held  open  as  in  the  previous  plate.  The  peritoneal  cavity  has  been 
opened  in  front  and  behind  the  cervix  and  the  uterus  has  been  brought  down  and 
inverted  by  means  of  traction  with  the  cat's-paw  retractor  (c). 


PLATE  CXLI. 
VAGIMAL  HYSTERECTOMY. 

The  uterus  has  been  removed ;  the  left  broad  ligament  is  still  held  with  clamp 
forceps,  the  ligature  being  in  place,  but  not  tied.  The  clamp  forceps  have  been 
removed  from  the  right  broad  ligament  (b)  and  the  ligature  has  been  tied.  A  piece 
of  iodoform  gauze  has  been  sutured  to  the  stumps  of  the  broad  ligaments  with  two 
Cat-gut  sutures  (c). 


PLATE  CXL1I. 
VAGINAL  HYSTERECTOMY. 

The  operation  completed.  The  orifice  held  open  by  the  specula  (c)  and  (d). 
The  vaginal  vault  (a)  closed  by  tying  the  sutures.  The  iodoform  gauze  drain  (b) 
in  place. 


SURGERY    OF    THE    FEMALE    PELVIS  787 

If  the  organ  is  no  longer  movable  the  patient  has  lived  longer  and  more 
comfortably,  in  our  experience,  if,  instead  of  removing  the  uterus  we  protect 
the  vaginal  walls  and  thoroughly  cauterize  the  entire  uterine  cavity  by 
introducing  cautery  irons  heated  to  red  heat.  The  most  convenient  form 
of  cautery  iron  for  this  purpose,  according  to  our  observation,  is  the  or- 
dinary soldering  iron  heated  in  a  tinner's  heater,  in  a  coal  fire  or  in  the  flame 
of  a  gas  stove.  A  number  of  these  irons  are  placed  in  the  flame  and  are 
introduced  into  the  cavity  of  the  uterus  successively  until  the  entire  cavity 
has  become  lined  with  an  eschar.  An  iodoform  gauze  pad  covered  with 
glycerine  is  then  inserted  and  a  retention  catheter  introduced  into  the  bladder. 
After  the  eschar  separates  the  connective  tissue  which  forms  during  the 
process  of  healing  contracts  the  organ  and  is  likely  to  retard  the  progress  of 
the  disease.  Many  of  these  patients  improve  so  much  that  the  surgeon  is 
likely  to  doubt  his  diagnosis,  and  one  of  our  cases,  which  seemed  at  the  time 
entirely  inoperable  and  hopeless,  lived  for  a  period  of  nineteen  years  and 
died  of  an  intercurrent  disease  without  having  had  a  recurrence  of  the  car- 
cinoma. A  number  of  other  cases  have  lived  from  three  to  ten  years.  Of 
course,  this  is  not  the  rule.  Most  patients  have  a  recurrence  within  one 
or  two  years,  to  which  they  succumb. 

Importance  of  Early  Diagnosis. 

The  most  important  point  regarding  the  treatment  of  carcinoma  of  the 
uterus,  however,  is  early  diagnosis  and  immediate  treatment.  In  order  to 
make  an  early  diagnosis  we  believe  it  is  important  that  the  surgeon  should 
make  a  careful  examination  in  every  case  in  which  there  is  the  slightest 
suspicion  of  malignancy.  This  is  true  especially  at  about  the  period  of  the 
menopause,  or  after  the  end  of  this.  In  almost  every  case  which  has  come 
under  our  care  for  treatment,  there  has  been  a  history  of  uterine  hemorrhages 
more  or  less  extensive.  If  these  hemorrhages  occur  in  a  patient  fifty  years 
of  age.  or  over,  the  physician  should  recognize  the  gravity  of  this  symptom. 
If  he  temporizes  without  having  satisfied  himself  positively  regarding  the 
diagnosis,  the  chances  are  that  by  the  time  the  diagnosis  is  made  the  case 
has  passed  beyond  the  stage  at  which  surgical  intervention  could  result  in 
permanent  benefit. 

Dangers  of  Diagnostic  Sections  and  Currettement. 

If  the  growth  begins  in  the  cervical  portion  of  the  uterus,  which  is 
its  most  common  origin,  then  it  can  be  at  once  discovered  upon  a  digital  ex- 
amination or  with  the  speculum.  In  case  the  tissues  appear  suspicious,  with 
this  history  and  at  this  age,  we  believe  that  a  hysterectomy  should  be  per- 
formed at  once.  In  many  cases  in  which  portions  of  the  malignant  growth  have 
been  removed  for  microscopical  examination  our  experience  has  been  that 
this  simple  procedure  has  resulted  in  the  stimulation  of  the  growth  to  such 
an  extent  that  even  in  very  recent  examples  there  has  been  no  permanent 
cure  after  this  method  of  diagnosis  has  been  employed.  \Ve  believe  that 
the  removal  of  portions  of  tissue  for  microscopical  examination  prior  to 
operation  should  be  most  strongly  condemned.  The  same  is  true  if  hem- 
orrhages occur  in  patients  after  the  menopause,  in  whom  neither  cervical 
carcinoma  nor  fibroid  of  the  uterus  can  be  diagnosed  by  physical  examination. 
In  these  it  has  been  the  practice  to  do  a  curettement  of  the  lining  of  the 
uterine  cavity  and  make  a  microscopical  examination  of  the  portions  curetted 
away.  Here,  again,  the  danger  of  infection  with  carcinoma  is  so  great  that 
we  believe  the  practice  should  be  absolutely  abandoned. 


788  SURGERY    OF    THE    FEMALE    PELVIS 

Operative  Technique. 

The  danger  of  infection  with  carcinoma  during  the  operation  should 
be  thoroughly  borne  in  mind,  because  it  is  not  necessary  during  the  opera- 
tion to  wound  any  portion  which  has  been  infected.  If  the  mass  projecting 
from  the  cervix  has  a  cauliflower  appearance  it  should  be  removed  by  means 
of  a  cautery  before  the  operation  is  begun,  because  in  this  way  all  of  the 
surfaces  through  which  the  incision  is  to  be  made  are  destroyed  by  the 
heat,  and  consequently  an  infection  from  them  is  not  possible.  After  the 
cervix  has  been  cleansed  by  means  of  the  cautery,  if  the  carcinoma  be 
cervical  in  character,  a  pair  of  volsellum  forceps  may  be  inserted  a  sufficient 
distance  away  from  the  carcinomatous  tissues  to  insure  that  they  do  not 
cause  implantation  into  the  latter.  The  vaginal  mucous  membrane  is  then 
severed  circularly  around  the  entire  cervix,  at  a  distance  of  at  least  two 
centimeters  from  the  margin  of  the  diseased  tissue,  by  means  of  a  Pacquelin 
or  an  electric  cautery.  We  believe  that  some  of  the  recurrences  in  our 
cases  have  been  due  to  a  neglect  of  this  plan.  Since  we  adopted  the  plan 
of  severing  the  vaginal  mucous  membrane  with  the  cautery  a  number  of 
years  ago  we  have  had  no  recurrences  in  the  vagina,  while  formerly  this 
was  a  common  location  for  recurrence. 

The  uterus  is  then  drawn  downward  and  the  dissection  carried  on  in- 
front  and  behind  by  means  of  the  cautery  until  the  peritoneal  layer  is  ap- 
proached, care  being  taken  throughout  this  part  of  the  operation  to  avoid 
injuring  the  bladder  in  front  and  the  rectum  behind.  The  location  of  the 
bladder  may  be  determined  by  occasionally  inserting  a  steel  sound  through 
the  urethra  throughout  the  progress  of  the  operation.  After  the  dissection 
has  been  carried  to  this  point  by  means  of  the  cautery,  the  peritoneal  cavity 
is  opened  anteriorly  by  blunt  dissection  with  the  finger,  and  then  it  is  opened 
posteriorly  in  the  same  manner  and  a  piece  of  sterilized  gauze  carried  behind 
the  cervix  into  the  cul-de-sac  of  Douglas  in  order  to  prevent  the  soiling  of 
the  latter  cavity  from  the  cervix.  The  fnndus  of  the  uterus  is  then  brought 
to  the  anterior  opening  in  the  peritoneal  cavity,  or  through  the  posterior 
opening,  according  to  the  direction  in  which  this  can  be  accomplished  most 
easily.  Tf  the  fundus  is  brought  down  posteriorly,  then  a  piece  of  sterile 
gauze  should  be  inserted  anteriorly  to  protect  the  peritoneal  cavity  against 
soiling-. 

The  manner  in  which  the  uterus  can  be  brought  down  most  conveniently 
is  by  means  of  the  cat's-paw  retractors,  as  indicated  in  Plate  CXXXIX.  The 
ovary  and  tube  on  one  side  are  then  brought  forward  into  the  wound  by 
means  of  forceps  placed  upon  the  broad  ligament,  or  by  digital  manipulation. 
Then  a  pair  of  heavv.  long-jawed  compression  forceps  is  applied  to  the 
broad  ligament  beyond  the  ovary  and  tube  from  above  downwards,  in  order 
to  avoid  the  ureters.  These  forceps  should  be  so  constructed  that  it  is  im- 
possible for  the  tissue  to  slip  out  of  their  grasp.  The  broad  ligament  is 
then  cut  along  these  forceps  and  a  second  pair  of  the  same  kind  is  applied 
to  the  remaining  portion  of  the  lateral  pedicle  containing  the  remainder  of 
the  broad  ligament,  together  with  the  uterine  artery.  The  remainder  of 
the  pedicle  is  then  severed  and  the  uterus  is  attached  now  only  upon  one 
side.  It  is  then  an  easy  matter  to  bring  out  the  other  ovary  and  tube  and 
to  clamp  the  pedicle  bevond  these  in  the  manner  which  has  just  been  de- 
scribed. The  uterus  is  then  entirely  cut  away.  A  strand  of  iodoform  gauze 
is  placed  over  the  ends  of  these  forceps  in  order  to  prevent  them  from 
doing  injury  by  coming  in  contact  with  the  intestines  in  the  peritoneal 


PLATE  CXLTII. 
Uterine  Carcinoma. 


Sl'RGERV    ()!•'    T  H  E     FEMALE     PELVIS  7QI 

cavity,  and  then  the  points  of  the  forceps  are  shoved  up  into  the  peritoneal 
cavity  beyond  the  vaginal  wound.  A  further  tampon  is  placed  in  the  open- 
ing in  the  vagina,  and  the  outlet  of  the  vagina  is  tamponed  with  a  piece 
of  iodoform  gauze,  thoroughly  saturated  with  vaseline,  in  order  to  prevent 
the  soiling  of  the  deeper  tampons  from  without.  The  introduction  of  a 
retention  catheter  and  the  application  of  the  external  dressing  completes 
the  operation. 

It  has  seemed  to  us  that  there  exists  a  distinct  advantage  in  using  the 
clamps  for  the  purpose  of  hemostasis  in  preference  to  a  ligature,  because 
the  line  of  incision  through  the  pedicle,  which  might  be  a  favorable  field 
for  infection  with  carcinoma,  is  thus  eliminated  on  account  of  the  sloughing 
which  takes  place  in  the  portion  contained  in  the  bite  of  the  forceps. 
After-care. 

The  forceps  are  left  unmolested  for  twenty-four  or  thirty-six  hours, 
when  they  are  loosened  and  left  in  place  so  that  the  portion  contained  in 
the  bite  of  the  forceps  may  spontaneously  retract  from  the  latter.  Several 
hours  later  the  forceps  can  be  withdrawn  without  giving  the  slightest  amount 
of  pain  to  the  patient,  while  if  they  are  withdrawn  at  once  upon  being  loos- 
ened the  act  is  usually  accompanied  by  a  considerable  amount  of  pain,  and 
occasionally  hemorrhage.  The  most  superficial  tampon  is  removed  at  the 
time  of  removing  the  forceps  and  fresh  vaseline  is  applied  to  the  parts. 
The  deeper  tampons  are  removed  from  the  fifth  to  the  eighth  day,  as  they 
become  loosened.  About  the  tenth  day  the  speculum  is  introduced  and 
sloughs  which  have  become  loosened  by  this  time  are  removed  by  means 
of  dressing  forceps.  After  the  last  piece  of  gauze  has  been  removed  the 
patient  is  given  warm  douches  of  some  mild  antiseptic  character,  from 
three  to  six  times  a  day.  care  being  taken  to  have  the  fountain  syringe 
very  slightly  elevated,  so  that  it  is  not  possible  for  the  stream  to  injure  the 
adhesions  which  have  formed  in  the  upper  portion  of  the  wound.  These 
douches  are  a  source  of  comfort  to  the  patient  and  are  perfectly  harmless 
if  given  in  this  manner.  The  retention  catheter  is  left  in  place  until  all  of 
the  gauze  tampons  have  been  removed,  unless  it  gives  rise  to  discomfort,  in 
which  case  it  may  be  extracted  sooner  and  the  urine  withdrawn  by  means 
of  catheterization.  If  the  catheter  is  left  in  place  too  long  it  may  become 
filled  with  phosphatic  concretions,  unless  a  few  drops  of  a  dilute  mineral 
acid  be  given  in  a  considerable  quantity  of  water  three  to  six  times  daily. 

A  very  comfortable  external  dressing  consists  of  pads  saturated  with 
one  part  of  alcohol  and  two  parts  of  hot  water,  and  covered  with  a  large 
piece  of  dry  cotton  held  in  place  by  means  of  a  T-bandage.     Aside  from 
this  the  after-treatment  is  the  same  as  in  any  ordinary  abdominal  section. 
Prognosis. 

The  prognosis  depends  upon  the  extent  of  the  invasion  of  the  tissues 
by  the  disease.  If  the  operation  is  performed  early  and  the  cautery  used 
in  severing  the  tissues,  and  the  remaining  steps  followed,  as  has  been  in- 
dicated, the  prognosis  is  fairly  good.  In  advanced  cases  of  carcinoma  the 
prognosis  is  bad. 

COMBINED  VAGINAL  AND    ABDOMINAL   HYSTERECTOMY. 

In  more  advanced  cases  the  combined  vaginal  and  abdominal  operation 
has  been  advised  by  many  authorities,  because  it  has  been  claimed,  espe- 


SURGERY    OF    THE    FEMALE    PELVIS 

cially  by  Ries,  that  it  will  be  possible  to  remove  the  infected  glands  by 
following  this  method,  and  thus  to  prevent  recurrence  in  cases  in  which 
the  removal  by  the  vaginal  route  would  be  useless.  It  is  doubtful  whether 
it  is  possible  to  remove  all  of  the  infected  glands  in  any  case  in  which 
the  lymph  nodes  at  some  distance  from  the  uterus  have  become  infected 
with  carcinoma,  but  there  is  no  doubt  that  this  operation  is  more  thorough 
than  the  one  just  described  and  the  increased  danger  is  so  slight  that  the 
operation  is  at  least  justifiable  in  any  case  in  which  it  seems  plain  that 
the  disease  cannot  be  removed  entirely  by  the  vaginal  route,  and  is  not 
sufficiently  advanced  to  absolutely  contraindicate  an  attempt  at  a  removal. 

In  our  own  experience  these  patients  have,  however,  lived  longer  as 
a  rule,  when  we  have  treated  the  growth  with  very  extensive  destruction 
with  the  actual  cautery,  which  seemed  to  be  more  far-reaching  in  its  effect 
than  removal  by  the  most  careful  dissection. 

In  making  the  combined  operation  it  is  important  to  remove  all  of  the 
lymph  nodes  in  the  broad  ligaments  and  along  the  iliac  vessels.  This  dis- 
section is  best  accomplished  by  splitting  the  peritoneum  and  then  dissecting 
away  the  fat  and  the  lymph  nodes  with  a  gauze  pad,  according  to  the  method 
described  in  connection  with  the  removal  of  fat  and  lymphatics  of  the  axillary 
space  for  carcinoma  of  the  breast. 

All  of  the  raw  surfaces  are  then  covered  with  peritoneum  and  a  gauze 
or  cigarette  drain  is  passed  down  into  the  vagina. 

It  is  best  to  begin  the  combined  operation  from  below,  burning  away  the 
vaginal  attachment  precisely  as  described  in  the  previous  operation  and 
grasping  the  broad  ligaments  from  below  and  clamping  the  lower  portion 
of  the  broad  ligament  on  each  side  with  strong  hemostatic  clamps  and  burn- 
ing between  these  and  the  cervix  with  the  actual  cautery.  This  space  is  then 
thoroughly  tamponed  with  gauze  and  then  the  patient  is  placed  in  the 
Trendelenburg  position  and  the  operation  completed  through  a  large  abdom- 
inal incision,  as  described  above. 

The  after-treatment  is  the  same  as  before  described. 

VAGINAL  HYSTERECTOMY  FOR    NON-MALIGNANT  CONDITIONS. 

In  severe  uterine  hemorrhage,  due  to  the  presence  of  small  uterine 
fibroids,  which  cannot  be  controlled  by  means  of  simpler  methods,  a  vaginal 
hysterectomy  is  indicated  because  of  its  easy  execution,  that  it  does  not  give 
rise  to  a  scar  and  is  as  safe  as  the  abdominal  method.  In  this  case  it  is  not 
necessary  to  make  the  vaginal  incision  by  means  of  the  cautery.  The  remain- 
ing steps  of  the  operation  are  the  same  as  in  vaginal  hysterectomy  for  car- 
cinoma, but  there  is  no  necessity  for  leaving  the  pressure  forceps  in  place, 
and  the  patient's  comfort  is  increased  by  applying  a  ligature  around  the 
portion  of  the  pedicle  containing  the  uterine  artery,  as  indicated  in  Plate 
CXL,  and  a  second  ligature  around  the  remaining  portion  of  the  pedicle, 
as  shown  in  Plate  CXLI,  so  that  two  ligatures  will  take  the  place  of  the 
two  pressure  forceps  in  the  operation  which  has  just  been  described.  The 
ligatures  should  be  passed  through  the  pedicle  in  a  manner  which  will  pre- 
vent their  slipping,  because  a  careless  application  of  ligatures  at  this  point 
might  result  in  a  dangerous  hemorrhage.  Two  cat-gut  stitches  are  inserted 
through  the  edge  of  the  wound  to  one  side  of  the  center  and  left  untied,  as 
indicated  in  Plate  CXL,  until  the  tampon  of  iodoform  gauze  has  been 
fastened  to  each  of  the  two  lateral  pedicles  by  means  of  a  small  cat-gut  stitch. 


SURGERY    OF    THE    FEMALE    PELVIS  793 

as  shown  in  Plate  CXL1.  The  tampon  should  then  be  shoved  up  into  the 
abdominal  cavity,  together  with  the  two  lateral  pedicles,  and  then  the  stitches 
in  the  wound  are  tied,  as  illustrated  in  Plate  CXLII.  This  provides  for  the 
approximation  of  the  two  lateral  pedicles  and  for  the  closure  of  the  vaginal 
wound,  and  also  for  a  sufficient  amount  of  capillary  drainage.  The  approxi- 
mation of  the  lateral  pedicles  is  especially  valuable  in  case  the  operation  is 
performed  for  the  relief  of  complete  prolapsus  of  the  uterus,  because  in  this 
manner  a  support  for  the  floor  of  the  pelvis  is  provided.  A  retention  catheter 
is  inserted  as  before  and  the  after-treatment  is  carried  out  in  the  same  man- 
ner, the  iodoform  gauze  tampon  being  removed  between  the  fifth  and  tenth 
day  after  the  operation. 

In  carcinoma  of  the  uterus  which  is  operated  early,  before  the  disease 
has  advanced  beyond  the  tissues  of  the  cervix,  this  operation  is  also  very 
satisfactory,  but  in  cases  which  have  advanced  beyond  the  incipient  stage  we 
have  had  more  satisfactory  results  when  we  have  used  the  clamp. 

In  place  of  using  the  ordinary  hemostatic  clamps  we  have  used  Doud's 
electric  cautery  clamp  in  many  cases.  This  clamp  is  applied  to  the  pedicle 
as  one  would  apply  an  ordinary  clamp,  then  a  current  of  electricity  is  passed 
through  the  clamp  for  fifteen  to  thirty  seconds,  which  thoroughly  cooks 
the  tissues  contained  in  the  bite  of  the  instrument.  This  at  once  secures  the 
pedicle  against  hemorrhage  and  destroys  any  malignant  tissue  which  may  be 
contained  in  the  pedicle. 

The  same  clamp  is  used  upon  the  pedicle  formed  by  the  broad  ligament 
in  the  abdominal  operation.  By  using  this  clamp  the  entire  operation  can 
be  performed  without  the  use  of  either  knife  or  ligature,  the  entire  surface 
being  covered  with  cauterized  tissue.  The  results  after  operations  performed 
with  the  use  of  this  instrument  have  been  most  satisfactory. 

The  patients  do  not  suffer  from  shock,  neither  do  they  suffer  from 
severe  pain  after  the  operation.  It  is  well  to  mention  these  facts  because 
they  dispose  of  theoretical  objections  that  might  arise. 

PROLAPSE    OF   THE    UTERUS. 

In  prolapsus  of  the  uterus  in  patients  advanced  in  years,  in  which  the 
tissues  of  the  broad  ligament  seem  to  be  fairly  substantial,  the  operation 
which  has  just  been  described,  performed  without  the  use  of  the  cautery 
clamp,  has  given  most  satisfactory  results.  In  case,  however,  the  entire  vag- 
inal mucous  membrane,  together  with  the  posterior  wall  of  the  bladder  and 
the  anterior  wall  of  the  rectum,  show  a  tendency  to  prolapse,  these  latter 
structures  are  likely  to  continue  to  descend  after  doing  the  operation  above 
outlined,  and  in  such  the  patients  will  be  but  slightly  improved  unless  a  more 
extensive  operation  is  chosen. 

The  operation  which  seems  to  invariably  give  relief  in  these  cases  con- 
sists in  the  additional  removal  of  the  entire  vaginal  mucous  membrane  and 
the  closure  of  the  entire  canal  by  means  of  buried  cat-gut  sutures.  The 
operation  which  has  just  been  described  is  performed  without  the  use  of  the 
cautery  clamp  and  with  the  exception  that  the  two  lateral  pedicles  are 
united  to  each  other  broadly  by  means  of  buried  chromicized  cat-gut  sutures, 
and  then  the  entire  mucous  lining  of  the  vagina  is  dissected  out  from  above 
downward,  leaving  a  raw  canal  throughout.  This  is  closed  by  a  series  of 
buried  cat-gut  sutures  from  above  downward,  and  at  last  the  skin  at  the  en- 
trance of  the  vagina  is  united  by  means  of  a  longitudinal  suture  extending 


794  SURGERY    OF    THE    FEMALE    PELVIS 

from  a  point  two  centimeters  above  the  meatus  urinarius  down  to  the  an- 
terior edge  of  the  perineum.  In  applying  the  buried  cat-gut  sutures  it  is 
important  that  neither  the  rectum  nor  the  bladder  be  wounded,  for  fear  of 
producing  a  recto-vesical  fistula. 

The  after-treatment  is  the  same  as  after  an  ordinary  abdominal  section. 
Prognosis. 

The  prognosis  in  this  operation  is  very  favorable.  In  prolapsus  of  the 
uterus  in  younger  patients  it  is  usually  found  that  the  displacement  is  due 
to  an  abnormal  elongation  of  the  cervix.  There  seems  to  be  a  tendency  on 
part  of  the  tissues  of  the  vagina  to  make  traction  upon  the  elongated  cervix 
and  thus  cause  a  prolapsus  of  the  uterus.  The  replacement  of  the  latter  is  of 
no  apparent  benefit  to  the  patient,  and  the  support  by  means  of  pessaries 
seems  to  be  of  no  avail.  If,  however,  the  following  operation  be  employed 
for  the  purpose  of  removing  the  elongated  cervix  the  broad  ligaments  seem 
to  be  able  to  support  the  uterus  in  its  normal  position,  and  the  organ  will 
remain  in  its  proper  position  without  any  further  support. 

Removal  of  Elongated  Cervix. 

A  circular  incision  is  made  about  the  end  of  the  elongated  cervix  and 
the  mucous  membrane  surrounding  the  latter  is  reflected  to  a  point  a  little 
below  the  upper  extremity  thereof.  This  point  may  be  at  a  considerable 
distance  from  the  lower  end  of  the  cervix,  as  shown  in  Plate  CXLIV,  which 
was  drawn  from  nature,  and  in  which  the  cervix  had  reached  the  length  of 
twelve  centimeters.  Upon  a  casual  examination  it  seemed  as  though  there 
were  a  prolapse  of  the  entire  uterus,  but  upon  careful  inspection  it  was 
found  that  only  the  elongated  cervix  projected.  The  mucous  membrane  was 
carefully  dissected  upwards  in  the  anterior  and  posterior  flap,  as  indicated 
in  Plate  CXLY.  and  severed  just  below  the  upper  extremity  of  the  cervical 
canal.  As  soon  as  this  portion  of  the  cervix  had  been  cut  away  the  uterus 
showed  a  tendency  to  slip  up  into  the  pelvic  cavity  and  had  to  be  held  down 
in  position  in  order  to  complete  the  operation,  which  consisted  in  covering  the 
stump  with  the  mucous  membrane  removed  from  the  portion  of  the  cervix 
cut  away,  as  shown  in  Plate  CXLVI.  This  method  insures  the  formation 
of  a  normal  cervix. 

As  has  been  stated  before,  the  uterus  showed  a  tendency  to  slip  up  into 
the  pelvis  and  take  up  a  normal  position  as  soon  as  it  was  released  from 
below,  even  in  this  greatly  exaggerated  case.  This,  however,  is  not  the 
history  in  patients  advanced  in  years  who  have  given  birth  to  a  number  of 
children.  Tn  these  the  hysterectomy  which  has  just  been  described  is  to  be 
preferred. 

In  cases  in  which  an  obliteration  of  the  vagina  is  not  desirable  it  is  best 
to  perform  the  abdominal  hysterectomy  described  elsewhere,  especial 
care  being  taken  to  construct  a  substantial  floor  for  the  vagina  by  firmly 
suturing  together  the  broad  and  the  round  ligaments  with  chromic  cat-gut. 
This  can  be  done  to  the  required  degree  by  carefully  overlapping  these  liga- 
ments. At  the  same  time  it  is  wise  to  suture  together  broadly  the  recti  mus- 
cles throughout  the  abdominal  incision. 

EROSION  OF  THE  CERVIX. 

In  many  patients,  but  especially  in  those  whose  occupation  compels 
them  to  stand  a  greater  part  of  the  day,  the  pressure  of  the  cervix  upon  the 


PLATE  CXL1V. 

EXCISION  OF  ELONGATED  CERVIX  UTERI. 
The   elongated  cervix    (a)    (b)    withdrawn   from   the   vaginal   orifice. 


PLATE  CXLV. 

EXCISION  OF  ELONGATED  CERVIX   UTERI. 

The  mucous  membrane  covering  the  cervix  has  been  reflected  by  making  an 
elliptical  incision  around  the  cervix  (a).  Thus  an  anterior  (b)  and  a  posterior  (c) 
mucous  flap  are  formed  and  the  projecting  cervix  is  amputated. 


PLATE  CXLVI. 
CLOSURE  OF  WOUND  IN  CERVIX. 

The  flaps  of  mucous  membrane  are  brought  down  over  the  stump,  sutured  to  the 
mucous  membrane  lining  the  uterine  cavity,  and  all  raw  surfaces  are  covered  with 
portions  of  the  mucous  membrane,  making  a  perfectly  uniform  stump  (a). 


PLATE  CXLV1I. 

AMPUT  \TION  OF  LACERATED  CERVIX  UTERI. 

The  uterus  is  drawn  down  with  volsellum  forceps  (b).  An  elliptical  incision 
is  made  around  the  cervix.  The  anterior  portion  (e)  is  dissected  down  to  the  cer- 
vical canal.  Then  sutures  (c)  and  (d)  are  inserted,  uniting  the  vaginal  with  the 
cervical  mucous  membrane.  These  are  left  untied  until  the  lateral  sutures  have  been 
applied.  Then  the  removal  of  the  cervix  is  completed. 


PLATE  CXLVIII. 

AMPUTATION  OF  CERVIX  UTERI  FOR  LACERATION. 

(b),  (c),  (d)  and  (e)  represent  the  sutures  which  unite  the  mucous  membrane 
of  the  vagina  with  that  of  the  cervical  canal,  preventing  closure  of  the  latter;  (f)  (g) 
and  (h)  (i)  represent  the  sutures  on  either  side  which  cover  the  raw  surface  result- 
ing from  the  excision  of  the  cervix. 


PLATE  CXLIX. 
AMPUTATION  OF  CERVIX  UTERI. 

This  plate  shows  the  operation  as  completed  after  all  of  the  sutures  have  been 
tied  and  superficial  sutures  have  been  inserted  to  secure  accurate  coaptation  of  the 
mucous  membrane. 


SURGERY    OF    THE    FEMALE    PELVIS  807 

tissues  upon  which  it  rests  results  in  a  condition  of  erosion,  which  in  turn 
results  in  the  formation  of  exceedingly  hard  cicatricial  tissue.  This  condi- 
tion is  most  common  in  women  who  have  borne  children,  because  in  these 
the  uterus  has  usually  not  undergone  complete  involution,  and  the  conse- 
quent increase  in  weight  increases  the  pressure  and  consequently  favors  the 
result  in  question. 

The  pressure  occurring  from  the  contraction  of  the  cicatricial  tissue  is 
likely  to  produce  the  symptoms  described  in  connection  with  laceration  of 
the  cervix,  and  the  same  treatment  is  indicated. 

LACERATION  OF  THE  CERVIX. 

Causative  Factors  and  Symptoms. 

In  a  considerable  proportion  of  patients  going  through  childbirth  the 
cervix  of  the  uterus  is  lacerated.  If  the  wound  is  not  kept  aseptic  the  heal- 
ing is  bound  to  be  slow,  and  there  must  result  a  variable  amount  of  connec- 
tive tissue.  In  case  of  a  second  delivery  the  tissues  are  less  elastic  than 
normal,  because  of  the  presence  of  this  cicatricial  tissue,  and  consequently  a 
further  laceration  is  almost  certain  to  occur,  which  is  apt  to  be  more  ex- 
tensive than  the  previous  one.  Where  the  patient  can  obtain  reasonable 
care  during  the  pregnancy,  and  during  and  after  confinement,  the  wound 
usually  heals  so  perfectly  that  it  requires  no  further  attention,  but  unfor- 
tunately there  is  a  large  class  of  women,  comprising  the  most  valuable 
women  in  the  country,  in  which  conditions  are  such  that  ideal  care  during 
pregnancy  and  during  the  after-confinement,  is  not  possible.  This  class 
comprises  the  wives  of  the  mechanics,  artisans,  farmers  and  laborers. 

The  patient  usually  gives  a  history  of  having  been  in  excellent  health 
at  the  time  of  her  marriage,  of  having  undergone  a  variable  number  of  nor- 
mal pregnancies  and  usually  a  certain  number  of  abortions ;  the  confinement 
has  generally  been  conducted  by  a  midwife ;  the  patient  has  felt  the  neces- 
sity of  caring  for  her  entire  household  during  her  pregnancy ;  she  has  had 
but  a  slight  amount  of  care  during  and  after  confinement ;  she  has  not  en- 
joyed the  benefits  of  a  trained  nurse  at  such  time ;  she  began  to  perform  her 
regular  labors  within  a  short  period  after  confinement ;  and  has  had  the  care 
of  her  infant  and  all  of  her  family  within  a  short  time  thereafter.  Usually 
the  first  confinements  made  no  marked  impression,  but  later  on  the  patient 
began  to  grow  old  apparently  rapidly,  to  suffer  from  the  sensation  of  weight 
in  the  pelvis,  and  from  pain  low  down  in  the  back,  and  she  usually  com- 
plains of  feeling  tired  most  of  the  time.  Constipation  and  lack  of  strength 
in  securing  evacuation  of  the  bowels  are  usually  complained  of.  Notwith- 
standing this,  the  patient  frequently  has  gained  in  weight,  her  abdominal 
walls  have  become  greatly  thickened  with  the  accumulation  of  this  fat,  but 
the  normal  tone  of  the  abdominal  walls  has  been  lost.  Later  on  the  patient 
has  complained  of  nervousness,  has  become  irritable,  her  digestion  is  im- 
paired, and  this  condition  frequently  continues  until  she  is  nearly,  if  not 
wholly,  bed-ridden. 

Upon  examination  the  perineal  support  of  the  uterus  is  found  to  be 
greatly  impaired,  the  vaginal  walls  are  loose  and  flabby,  the  cervix  is 
greatly  thickened  and  edematous,  and  in  a  majority  of  patients  there  is  a 
laceration  of  the  left  side.  Occasionally  there  are  several  other  lacerations 
of  the  cervix,  all  filled  with  hard,  cicatricial  tissue.  The  uterus  is  found  upon 
bi-manual  examination  to  be  considerably  hypertrophied,  sometimes  twice  or 


808  SURGERY    OF    THE    FEMALE     PELVIS 

thrice  the  normal  size — involution  not  having  taken  place  after  the  confine- 
ments and  abortions.     The  fundus  of  the  uterus  may  be  retroverted  or.  it 
may  be  in  a  nearly  normal  position.     The  entire  organ  is  likely  to  be  some- 
what prolapsed  and  displaced  backward. 
Preparatory  Treatment. 

This  should  be  the  same  as  for  any  ordinary  operation,  unless  the  cervix 
is  covered  by  a  septic  ulcer.  Tn  such  instance,  it  is  wise  to  place  her  in 
bed  for  a  few  days  before  the  operation  is  performed,  to  give  large,  very  hot 
douches  from  three  to  six  times  a  day,  and  at  night  apply  some  antiseptic, 
such  as  compound  tincture  of  iodine,  equal  parts  of  compound  tincture  of 
iodine,  glycerine  and  carbolic  acid,  or  a  tampon  of  twenty-five  per  cent, 
ichthyol  in  glycerine.  During  this  period  of  treatment  the  patient  should 
also  received  mild  laxatives  and  light  diet. 
Technique. 

The  treatment  we  have  found  most  valuable  in  these  cases  consists  in 
the  removal  of  all  of  the  hardened  tissue  in  the  cervix  and  then  covering  the 
abraded  surface  with  vaginal  mucous  membrane.  A  broad  vaginal  speculum 
is  introduced,  as  shown  in  Plate  CXLVIT,  and  a  volsellum  forceps  applied  to 
the  posterior  lip  of  the  cervix.  With  this  it  is  drawn  downward  and  a  little 
forward,  and  an  elliptical  incision,  including  all  the  hardened  tissue  in  the 
cervix,  is  made  by  a  sharp  scalpel.  The  posterior  lip  is  not  entirely  severed 
during  this  stage,  but  the  anterior  lip  is  severed  down  to  the  cervical  canal. 
Then  two  chromicized  cat-gut  stitches  are  applied  to  the  anterior  lip  in  the 
following  manner :  One-eighth  of  an  inch  of  vaginal  mucous  membrane  is 
grasped  with  a  short-curved  needle,  as  shown  in  Plate  CXLVII.  The 
needle  at  the  same  time  grasps  about  one-third  of  the  thickness  of  the  un- 
derlying muscle ;  then  it  is  reintroducecl  into  the  cervical  tissue  and  the  same 
amount  of  tissue,  including  the  mucous  membrane  lining  the  cervix,  is 
grasped  with  these  sutures.  These  sutures  are  then  left  untied  until  the  re- 
maining portion  of  the  operation  has  been  completed,  when  their  tying  will 
approximate  perfectly  the  vaginal  mucous  membrane  and  that  lining  the 
cervical  canal.  These  two  sutures  will  serve  to  manipulate  the  uterus  during 
the  remainder  of  the  operation.  The  hardened  tissue  is  now  completely  cut 
away,  leaving  the  cervix  as  shown  in  Plate  CXLVITT.  Two  further  sutures 
are  inserted  posteriorly,  corresponding  to  those  applied  anteriorly  before  the 
cervix  was  entirely  cut  away.  These  are  also  left  untied.  Two  additional 
sutures  are  then  passed  on  each  side,  grasping  the  mucous  membrane  in 
front ;  then  to  the  substance  of  the  cervix  to  each  side  of  the  cervical  canal ; 
then  to  the  mucous  membrane  behind.  After  all  of  these  sutures  have  been 
applied  they  are  tied  successively,  the  outer  ones  being  tied  first;  the  two 
sutures  grasping  both  the  vaginal  and  the  cervical  mucous  membranes  being 
left  to  the  last.  After  all  of  these  have  been  tied  the  entire  abraded  sur- 
face will  be  covered,  with  the  addition  of  a  few  coaptation  sutures,  as  indi- 
cated in  Plate  CXLTX. 

This  leaves  the  cervix  in  as  nearly  an  ideal  condition  as  possible,  and 
in  case  of  a  future  pregnancy  it  is  no  more  likely  to  become  lacerated  than 
it  would  be  had  it  never  had  a  laceration  and  reparative  operation.  In  quite 
n  considerable  'number  of  patients  we  have  observed  the  outcome  after  a 
future  confinement,  and  in  all  of  these  the  condition  has  been  most  satis- 
factory. 

The  chromicized  cat-gut  to  be  used  should  be  prepared  so  as  to  absorb 


SURGERY    OF    THE    FEMALE    PELVIS  8(X) 

within  about  two  weeks.  This  will  dispose  of  the  annoyance  of  removing 
the  stitches.  It  is  important  in  this  operation  that  the  stitches  be  not  drawn 
too  tightly,  as  a  certain  amount  of  edema  is  sure  to  occur,  which  is  greatly 
increased  if  the  stitches  are  tied  tightly.  In  this  event  each  stitch  will  leave 
a  line  of  pressure  necrosis  across  the  surface  to  be  occupied  by  hard  nodu- 
lar tissue.  The  removal  of  the  hard  connective  tissue  is  the  most  important 
benefit  the  patient  derives,  and  consequently  nothing  should  be  done  in  the 
operation  which  might  give  rise  to  a  recurrence  of  this  state,  even  to  a 
slight  extent. 

After  the  wound  has  healed  the  surface  should  be  perfectly  soft  and 
covered  with  loose  connective  tissue,  and  the  impression  upon  making  a  digi- 
tal examination  should  be  very  similar  to  that  one  obtains  in  making  an 
examination  of  a  cervix  which  has  not  been  disturbed  by  pregnancy  or 
confinement. 

After  the  operation  has  been  completed  the  uterus  should  be  replaced 
in  the  normal  position  by  bi-manual  manipulation.  It  frequently  happens 
that  during  operations  the  uterus  has  been  drawn  down  considerably,  and 
after  the  work  is  completed  it  is  quite  out  of  place,  and  unless  the  surgeon 
takes  the  precaution  of  properly  replacing  the  organ  at  the  conclusion  of  his 
operation  it  may  remain  displaced  during  the  entire  time  the  patient  is  con- 
fined to  bed.  In  this  way  considerable  harm  may  follow. 

The  after-treatment  consists  of  rest  in  bed  for  at  least  two  weeks ;  the 
administration  of  from  three  to  six  large,  hot  douches  a  clay ;  a  light  diet, 
and  the  use  of  mild  laxatives. 

In  almost  all  of  these  patients  there  are  other  conditions  which  must 
be  corrected,  and  the  prognosis  will  be  considered  in  connection  with  them. 

LACERATION  OF  THE  PERINEUM. 

This  deformity  almost  invariably  accompanies  the  condition  just  de- 
scribed, although  if  the  patient  has  had  the  care  of  a  physician  during  con- 
finement the  laceration  is  nowadays  usually  repaired  at  once  after  its  oc- 
currence ;  consequently  there  are  comparatively  few  old  lacerations  now  in 
patients  who  have  this  proper  attention.  These  cases  belong  to  a  class  in 
which  the  lacerations  occurred  at  a  time  when  the  general  practitioner  was 
not  so  careful  to  examine  and  repair  a  torn  perineum  after  confinement  as 
he  is  to-day,  and  in  the  class  still  being  confined  by  the  midwife. 

The  history  is  the  same  as  that  just  given  in  connection  with  laceration 
of  the  cervix.  The  laceration  may  vary  in  degree,  extending  quite  into  the 
rectum  for  a  slight  distance,  or  for  several  inches,  or  only  through  a  por- 
tion of  the  perineal  body,  or  only  through  the  upper  or  the  lower  portion — 
which  may  be  determined  upon  inspection  or  by  making  a  digital  examina- 
tion. There  may  exist  at  the  same  time  a  bulging  forward  of  the  rectum 
between  the  margins  of  the  lacerated  tissues,  the  mucous  membrane  of  the 
vagina  and  the  wall  of  the  rectum  being  carried  forward  by  the  pressure  of 
the  feces  in  the  latter,  forming  a  rectocele.  If  this  condition  be  present 
it  usually  interferes  very  seriously  with  the  evacuation  of  the  bowls. 

In  some  cases  the  skin  and  mucous  membrane  may  have  remained  per- 
fectly intact,  and  still  with  virtually  no  perineal  support  left,  because  while 
the  skin  and  mucous  membrane  were  not  injured,  on  account  of  their  elas- 
ticity, the  transverse  perineal  muscles  were  completely  torn  and  the  levator 
ani  muscles  separated. 


8lO  SURGERY    OF    THE    FEMALE    PELVIS 

Technique. 

A  transverse  incision  is  made  through  the  septum  remaining  between 
the  rectum  and  vagina,  and  the  tissues  of  the  vaginal  wall  carefully  dis- 
sected loose  from  those  of  the  rectal  wall,  forming  a  large  flap,  which  is 
carried  forward  into  the  vagina — the  entire  septum  being  split  from  side  to 
side.  After  the  incision  through  the  skin  and  through  a  short  distance  of 
cicatricial  tissue  which  usually  exists  underneath  the  skin,  the  separation  of 
these  flaps  may  be  accomplished  most  readily  by  grasping  the  vaginal  flap 
with  dissecting  forceps  and  shoving  away  this  section — the  posterior  flap — 
by  means  of  the  finger,  covered  with  soft  thickness  of  moist  aseptic  gauze. 
In  this  manner  a  flap,  as  shown  in  Plate  CL,  can  be  produced  in  a  few 
moments.  This  exposes  the  tissues  on  each  side  which  originally  formed 
the  perineum,  and  by  carefully  uniting  these,  after  the  manner  to  be  de- 
scribed, a  perineum  may  be  constructed  which  will  be  as  thorough  a  support 
as  the  original  structure.  The  anterior  flap  is  drawn  forward  and  a  row 
of  interrupted  tension  sutures  applied,  as  indicated  in  the  plate,  the  first 
suture  beginning  directly  underneath  the  skin  and  grasping  the  submucous 
tissues  successively  and  issuing  on  the  opposite  side  directly  underneath  the 
skin.  The  last  suture  posteriorly  is  applied  precisely  in  the  same  manner. 

It  will  be  seen  that  after  the  first  suture  has  been  tied  there  will  be  a 
perfect  floor  to  the  vagina,  no  matter  how  deep  the  laceration  may  have 
been.  The  same  is  true  after  the  last  stitch  posteriorly  has  been  tied,  there 
will  be  a  new  roof  for  the  rectum,  even  though  the  laceration  may  have 
extended  a  considerable  distance  up  into  the  same.  It  is  plain  that  if  these 
two  stitches  are  properly  applied  -that  a  recto-vaginal  fistula  after  this  op- 
eration is  impossible. 

The  remaining  deep  stitches  are  inserted  through  the  tissues  on  each 
side,  beginning  near  the  skin  and  passing  down  to  a  point  just  in  front  of 
the  rectum,  then  passing  over  to  the  other  side  in  front  of  the  rectum  and 
out  through  the  tissues  precisely  opposite  to  the  manner  of  introduction  on 
the  other  side.  From  two  to  five  of  these  sutures  are  inserted  and  left  un- 
tied. Ordinary  cat-gut  sutures  would  undoubtedly  suffice  for  this  purpose, 
but  in  our  practice  we  have  used  chromicized  cat-gut,  which  will  be  ab- 
sorbed after  about  twentv  days.  A  continuous  cat-gut  suture  is  then  in- 
troduced, as  shown  in  Plate  CL.  for  the  purpose  of  uniting  the  tissues 
on  one  side  to  the  corresponding  tissues  on  the  opposite,  a  small  bite  being 
taken  with  a  short  curved  needle  and  care  being  exercised  to  avoid  wound- 
ing the  rectum. 

It  is  important,  again,  to  draw  these  stitches  very  loosely,  for  fear  of 
causing  pressure  necrosis.  The  suturing  can  be  done  from  above  down- 
ward, then  from  below  upward,  then  from  above  downward  again,  the 
same  suture  being  used  continuously. 

After  all  the  tissues  have  been  placed  in  accurate  coaptation  in  this 
manner,  the  continuous  suture  is  tied  and  then  the  stay  sutures  are  tied 
loosely  over  this,  and  then  the  skin  is  united  carefully  with  a  continuous 
cat-gut  suture.  It  is  clear  that  a  rectocele  cannot  occur  after  this  opera- 
tion, because  the  space  originally  occupied  by  the  rectocele  is  completely 
filled  in  by  the  sutures.  This  operation  will  give  satisfactory  results  with 
any  one  of  the  various  forms  of  laceration  of  the  perineum  enumerated 
above. 

Concomitant  Hemorrhoids. 

A  considerable  number  of  these  patients  suffer  at  the  same  time  from 


PLATE  CL. 
PERIXEORRHAPH  v. 

The  recto-vaginal  septum  has  been  split  and  the  vaginal  flap  (e)  drawn  forward. 
A  silkworm  gut  suture  (aa)  has  been  applied  to  the  anterior  flap,  which,  when  tied, 
will  make  a  new  floor  for  the  vagina.  A  similar  suture  (b)  is  applied  to  the  pos- 
terior flap.  These  sutures  extend  to.  but  not  through,  the  mucous  membrane  in 
either  case.  The  sutures  caught  in  the  forceps,  marked  (c),  pass  through  the  lateral 
flaps,  but  they  are  left  untied  until  each  successive  tissue  on  either  side  has  been 
united  with  the  same  tissue  on  the  opposite  side  by  means  of  the  continuous  cat-gut 
suture  marked  (d).  After  the  deep  tissues  have  been  united  with  the  silkworm  gut 
sutures  (c)  are  tied. 


PLATE  CLI. 
EXCISION  OF  URETHRA. 

The  urethra  has  been  dissected  out  and  drawn  forward  with  forceps  and  partly 
severed.  The  remaining  stump  is  being  sutured  to  the  skin  with  interrupted  cat-gut 
sutures,  two  sutures  being  in  place  and  the  third  one  being  applied. 


SURGERY    OF    THE    FEMALE    PELVIS  815 

hemorrhoids.  It  is  usually  sufficient  simply  to  dilate  the  sphincter  ani 
muscles  thoroughly  before  this  operation  is  performed,  in  order  to  relieve 
the  patient  of  that  trouble.  In  cases  where  there  are  hemorrhoids  of  con- 
siderable size,  however,  the  operation  already  described  should  be  employed, 
but  the  hemorrhoids  on  the  anterior  surface  of  the  rectum  should  not  be 
disturbed  for  fear  of  causing  an  infection  of  the  perineal  wound.  In  case 
a  hemorrhoidal  swelling  is  directly  on  the  anterior  surface  of  the  rectum, 
this  invariably  disappears  after  the  perineum  has  been  repaired,  which  is 
not  always  the  case  with  those  located  on  the  lateral  or  the  posterior  sur- 
faces of  the  rectum,  hence  the  latter  should  be  removed  with  clamp  and 
cautery,  or  with  the  ligature. 

After-treatment. 

The  patient  should  remain  in  bed  for  at  least  two  weeks,  and  if  possible 
it  is  better  to  have  her  remain  a  week  or  two  longer,  because  the  benefit 
derived  from  perfect  rest  is  quite  important,  and  if  this  be  prolonged  some- 
what it  is  quite  worth  while.  Many  of  these  patients  also  suffer  from  gas- 
tric disturbances ;  consequently  they  are  greatly  benefited  by  careful  diet- 
ing, which  may  be  carried  out  during  their  stay  in  the  hospital  without  inter- 
fering with  the  progress  of  the  recovery  from  the  operation.  We  have 
found  that  many  suffer  at  the  same  time  from  an  inability  to  masticate  their 
food  properly,  because  during  their  long-continued  illness  they  have  not 
given  needful  attention  to  the  preservation  of  the  teeth.  Among  the  class 
of  working  women  in  whom  these  operations  are  especially  indicated  one 
frequently  finds  the  mouth  filled  with  decayed  roots,  and  it  is  consequently 
a  good  plan  invariably  to  examine  the  teeth  and  during  the  anesthesia 
remove  any  decayed  roots  that  may  be  present,  and  to  direct  these  patients 
after  recovery  from  their  operations  to  have  the  remaining  teeth  thoroughly 
repaired,  and  in  case  there  are  many  missing  to  procure  artificial  dentures. 
This  will  also  aid  in  building  up  these  sufferers  very  greatly  after  the  return 
home  from  their  operations. 

These  patients  should  be  especially  cautioned  against  constipation,  as 
this  will  aid  greatly  in  securing  a  satisfactory  recovery.  If  these  various 
precautions  are  taken  the  prognosis  is  usually  very  satisfactory.  A  worn-out 
woman  between  the  age  of  thirty-five  and  forty-five  years  usually  recovers 
to  such  an  extent  that  within  a  year  or  two  she  will  readily  be  taken  to  be 
five  or  ten  years  younger  than  she  was  before  the  operation. 

In  many  of  these  cases  there  is  at  the  same  time  a  retroversion  or  ret- 
roflexion  of  the  uterus,  which  may  easily  be  corrected  by  making  bi- 
manual  manipulations,  but  in  which  the  uterus  will  not  maintain  its  cor- 
rected position  for  any  considerable  length  of  time. 

Both  of  the  operations  which  have  just  been  described  must  usually 
be  performed  on  the  same  patient.  The  result  of  the  amputation  of  the 
cervix  will  be  primarily  to  remove  an  amount  of  irritating  cicatricial  tissue, 
to  remove  a  suppurating  ulcerated  surface,  and  this  in  turn  will  result  in 
the  natural  absorption  of  the  hypertrophy  of  the  uterus,  which  is  present 
at  the  time  of  the  operation.  Within  a  few  months  an  hypertrophied  uterus 
upon  which  this  operation  has  been  performed  will  usually  be  reduced  to  an 
almost  normal  size.  This  in  itself  will  increase  the  likelihood  of  the  organ 
remaining  in  its  normal  position.  Then,  further,  the  repair  of  the  perineum 
will  increase  this  likelihood  still  more,  by  supplying  additional  support  for 
the  uterus.  If,  however,  the  retroversion  or  rctroflexion  persists  after  these 


8l6  SURGERY    OF    THE    FEMALE    PELVIS 

operations  or  if  the  tendency  to  these  displacements  is  so  great  that  it  does 
not  seem  likely  that  they  will  he  corrected  by  means  of  these  two  opera- 
tions, then  a  third  procedure  is  indicated  for  the  direct  relief  of  this  condi- 
tion. 

In  cases  in  which  this  tendency  to  retroversion  and  retroflexion  exists 
the  round  ligaments  which  normally  hold  the  uterus  forward  have  been  so 
severely  stretched  that  they  are  no  longer  able  to  furnish  normal  support. 

ALEXANDER  OPERATION. 

An  incision  three  centimeters  in  length  is  made  directly  over  the  exter- 
nal abdominal  ring  in  the  direction  of  the  inguinal  canal.  It  is  carried 
down  through  the  skin  and  deep  fascia  to  the  fascia  of  the  external  oblique 
abdominal  muscle.  It  is  important  that  this  incision  be  carried  quite  through 
the  deep  fascia,  because  if  any  portion  of  this  fascia  is  permitted  to  remain 
undivided  the  surgeon  may  experience  considerable  difficulty  in  locating  the 
round  ligament. 

After  the  fascia  of  the  external  oblique  has  been  thoroughly  exposed, 
the  external  abdominal  ring  can  be  located  by  palpation,  as  it  gives  the 
feeling  of  less  resistance  at  this  point  than  at  any  other.  The  fascia  of  the 
external  oblique  is  now  split  in  the  direction  of  its  fibers  at  this  point,  which 
will  expose  a  small  mass  of  fat  directly  in  the  external  abdominal  ring.  If 
this  mass  of  fat  is  now  grasped  by  means  of  a  pair  of  hemostatic  forceps. 
it  will  contain  the  round  ligament,  which  may  appear  as  a  thread-like  band, 
or  may  take  the  form  of  a  cord  of  considerable  size,  sometimes  as  large  as 
two  millimeters  in  diameter.  It  is  important  to  dissect  this  out  carefully, 
because  if  once  lost  it  may  be  difficult  to  find  it  again.  This  ligament 
should  be  examined  carefully,  and  the  genital  branch  of  the  genito-crural 
nerve  which  accompanies  it  should  be  separated  as  its  destruction  results  in 
a  paralysis  of  sensation  in  the  parts  to  which  it  is  supplied — which  is  likely 
to  be  the  cause  of  considerable  annoyance. 

After  the  round  ligament  has  been  freed  from  its  connective  tissue  at- 
tachments, it  should  be  drawn  up  very  gently  until  the  infundibuliform 
process  of  the  peritoneum  becomes  apparent.  The  ligament  is  then  drawn 
out  until  it  gives  the  sensation  of  drawing  the  uterus  against  the  abdom- 
inal wall.  Then  a  pad  of  sterile  gauze  is  passed  through  under  the  liga- 
ment and  the  same  steps  are  carried  out  on  the  opposite  side.  After  both 
ligaments  have  been  loosened  and  drawn  up  until  this  sensation  of  pulling 
the  uterus  against  the  abdominal  wall  is  felt  on  each  side,  then  each  is  re- 
laxed for  a  distance  of  about  two  or  three  centimeters,  in  order  to  give  the 
uterus  the  desired  mobility,  and  a  few  stitches  of  fine  chromicized  cat-gut 
are  passed  through  each  ligament  doubled  upon  itself  in  order  to  remove 
the  slack  in  the  ligament.  Then  a  few  stitche's  are  inserted  between  the 
doubled  ligament  and  the  posterior  surface  of  the  fascia  of  the  external 
oblique. 

In  case  the  inguinal  canal  has  been  stretched  during  the  operation,  the 
pillars  of  the  canal  are  drawn  together  by  a  few  stitches.  The  suturing  of 
the  fascia  of  the  external  oblique  abdominal  muscle  completes  the  operation. 

Much  has  been  written  concerning  the  likelihood  of  suppuration  taking 
place  in  these  operations.  We  believe  that  this  is  due  to  the  fact  that  a 
considerable  portion  of  the  operation  is  performed  upon  tissues  with  slight 
vitalitv,  and  if  with  these  the  surgeon  has  a  tendency  to  tie  his  sutures  too 


SURGERY    OF    THE    FEMALE    PELVIS  817 

tight  the  resulting  pressure  necrosis  will  supply  an  excellent  culture  medium 
for  the  micro-organisms.     If  the  sutures  are  tied  just  tightly  enough  to  se- 
cure coaptation,  and  not  enough   to  cause  pressure  necrosis,  there  is  no 
proneness  towards  suppuration. 
After-treatment. 

If  this  operation  is  performed  in  connection  with  the  last  two  just  de- 
scribed, no  special  after-treatment  will  be  required.  If  it  is  done  for  the  re- 
lief of  retroversion  or  retroflexion  of  the  uterus  in  cases  in  which  there  is 
no  indication  for  the  other  two  operations,  then  it  is  wise  for  the  patient 
to  wear  a  carefully  fitted  pessary  for  at  least  two  months  afterwards,  so 
that  the  adhesions  between  the  round  ligaments  and  their  new  attachments 
will  have  become  perfectly  firm  before  any  weight  is  placed  upon  them. 

Prognosis. 

If  this  operation  is  undertaken  only  in  proper  cases,  namely,  in  those 
in  which  no  force  whatever  is  required  in  replacing  the  uterus  into  its  nor- 
mal position,  cases  in  which  the  uterus  can  be  retained  in  its  normal  posi- 
tion by  means  of  a  carefully  applied  pessary,  the  prognosis  is  almost  in- 
variably good.  Then  the  operation  does  not  interfere  with  a  future  preg- 
nancy, and  after  delivery  the  uterus  will  maintain  a  normal  position,  show- 
ing that  the  changes  during  pregnancy  have  no  tendency  to  destroy  the  ben- 
efits secured  for  the  patient  by  this  operation.  It  is  important,  we  believe, 
that  the  uterus  should  be  placed  in  the  normal  position  by  bi-manual  manip- 
ulation before  this  operation  is  done.  It  also  seems  important  that  the 
round  ligaments  should  not  be  shortened  too  much,  in  order  to  permit  the 
normal  mobility  of  the  uterus. 

VESICOCELE. 

In  this  same  class  of  cases,  as  has  been  stated  above,  there  is  also  fre- 
quently an  injury  to  the  anterior  vaginal  wall,  as  well  as  to  the  posterior, 
consisting  in  a  separation  of  the  tissues  supporting  the  bladder  posteriorly. 
As  a  result  of  this  injury  the  bladder  will  bulge  into  the  vagina  more  and 
more,  so  that  in  extreme  cases  it  may  project  in  a  sac-like  protrusion  from 
the  vagina.  This  will  result  in  retention  of  a  certain  amount  of  urine,  in 
obstruction  to  the  passage  of  urine,  and  as  infection  of  this  residual  urine 
is  likely  to  occur  this  condition  usually  results  in  the  production  of  a  cystitis. 
If  this  affection  is  present  only  to  a  very  slight  extent,  the  operation  just 
described  for  the  repair  of  a  laceration  of  the  perineum  will  usually  suf- 
fice to  support  the  bladder  posteriorly,  and  as  a  consequence  the  symptoms 
resulting  from  the  vesicocele  will  subside.  If  the  vesicocele  is  pronounced, 
however,  this  operation  alone  will  not  suffice.  It  will  then  become  necessary 
to  excise  an  elliptical  portion  of  the  anterior  vaginal  wall,  with  its  greater 
diameter  extending  parallel  with  the  direction  of  the  vagina.  This  will  ex- 
pose the  ends  of  the  torn  tissues.  The  latter  may  be  united  by  a  continuous 
suture  extending  parallel  with  the  direction  of  the  vagina.  If  the  lacerated 
tissues  are  thus  united  the  mucous  membrane  of  the  bladder  will  contract 
and  the  vesicocele  be  abolished.  It  is  important,  however,  that  there  be  no 
pressure  upon  the  sutures  shortly  after  the  operation,  and  in  order  to  pre- 
vent this  it  is  wise  to  insert  a  retention  catheter  directly  after  the  operation, 
which  will  insure  an  empty  bladder,  and  consequently  absence  of  pressure 
upon  the  sutured  wound.  The  perineum  should  be  sutured  simultaneously, 
in  order  to  further  support  the  posterior  wall  of  the  bladder. 


8l8  SURGERY    OF    THE    FEMALE    PELVIS 

After-treatment. 

The  patient  should  be  given  large  quantities  of  pure  water  to  drink  so 
as  to  dilute  the  urine  and  make  it  non-irritating,  and  prevent  the  accumu- 
lation of  phosphates  in  the  catheter.  A  large,  hot  douche  should  be  given 
from  three  -to  six  times  a  day  to  keep  the  vaginal  wound  clean.  In  all 
other  respects  the  after-treatment  is  the  same  as  following  the  operations 
just  described. 

The  retention  catheter  is  removed  at  the  end  of  one  and  one-half  or 
two  weeks,  but  if  there  is  any  tendency  of  the  bladder  to  become  sufficiently 
distended  to  stretch  the  wound  the  catheter  should  be  reintroduced. 
Prognosis. 

The  prognosis  after  this  operation  is  satisfactory  unless  the  deformity 
has  existed  for  so  long  a  time  that  the  elasticity  of  the  mucous  membrane 
of  the  bladder  has  been  destroyed. 

EXCISION    OF   THE    LABIA    MAJORA,  MINORA  AND   CLITORIS  FOR 

CARCINOMA. 

In  carcinoma  of  any  one  of  these  parts,  the  excision  of  the  entire  part, 
together  with  a  considerable  portion  of  the  surrounding  tissues,  is  indicated, 
but  the  most  important  portion  of  the  treatment  to  be  carried  out  consists  in 
the  careful  dissection  of  the  inguinal  lymphatic  glands,  an  operation  which 
has  been  described  in  connection  with  carcinoma  of  the  penis. 

In  our  own  work  we  have  employed  the  electro-cautery  or  the  Pacquelin 
cautery  for  the  removal  of  these  growths,  with  the  hope  of  preventing  the 
inoculation  of  surrounding  tissues  that  would,  or  might,  follow  the  knife. 
In  all  of  these  cases  it  is  important  to  dissect  away  the  fat  and  lymph  nodes 
of  the  inguinal  regions,  making-  use  of  the  gauze  dissection  because  in  this 
way  recurrence  can  often  be  prevented. 
Prognosis. 

A  very  extensive  and  thorough  operation  done  early  before  the  disease 
has  progressed  far,  promises  well  for  a  permanent  recovery,  which  is  not 
the  case  when  the  disease  is  greatly  advanced.  It  is  most  important  to  make 
a  very  extensive  operation  when  the  patient  first  comes  under  the  care  of 
the  surgeon,  even  though  the  area  involved  be  very  small. 

EXCISION  OF  THE  URETHRA. 

This  operation  may  be  indicated  for  the  relief  of  epithelioma  of  the 
meatus,  a  condition  not  very  uncommon,  or  for  a  prolapsus  of  the  urethra. 
If  it  is  performed  for  the  relief  of  epithelioma  the  same  precautions  must 
be  observed  as  in  operations  for  the  relief  of  epithelioma  elsewhere.  A 
sufficient  amount  of  tissue  must  be  removed  to  insure  the  greatest  possible 
freedom  from  recurrence. 

Technique. 

A  circular  incision  is  made  around  the  urethra  for  a  sufficient  distance 
to  remove  all  diseased  tissues.  Then  the  urethra  is  dissected  out  upwards 
towards  the  bladder  until  a  point  is  reached  a  sufficient  distance  from  the 
disease ;  then  the  remnant  of  the  canal  is  drawn  forward  and  a  stitch  ap- 
plied between  this  and  the  outer  skin,  as  indicated  in  Plate  CLI.  The 
urethra  is  then  partly  cut  off  transversely  and  a  second  stitch  applied  a  short 


SURGERY    OF    THE    FEMALE    PELVIS  819 

distance  from  the  first.  In  this  manner  the  urethra  is  successively  stiched  to 
the  skin  and  cut  off  until  the  entire  structure  has  been  severed.  In  this,  as 
in  every  operation  in  which  a  tubular  structure  has  to  be  brought  forward 
and  attached  to  the  skin,  it  is  best  to  apply  a  few  stay  sutures  through  the 
wall  of  the  tube  at  some  distance  back  from  the  outer  end,  and  to  attach 
these  stitches  to  the  outer  structures,  so  that  but  little  tension  is  left  for  the 
stitches,  which  are  applied  immediately  through  the  end  of  the  tube  and 
through  the  skin.  In  this  manner  there  is  much  less  danger  of  retraction 
from  the  tube  and  consequent  constriction  of  its  end  than  if  simply  a  single 
row  of  sutures  is  employed. 

Should  it  seem  difficult  to  introduce  a  catheter  through  the  opening  for 
the  purpose  of  emptying  the  bladder  from  time  to  time  a  small  retention 
catheter  may  be  passed  while  the  patient  is  still  anesthetized.  This  catheter 
is  removed  after  a  few  days  and  the  patient  is  usually  able  thereafter  to 
empty  the  bladder  spontaneously. 

The  after-treatment  is  the  same  as  in  operation  for  cystocele. 

VESICO-VAGINAL    FISTULA. 

Patients  suffering  from  this  condition  usually  give  the  history  of  a  long 
continued  labor  with  or  without  the  use  of  forceps.  Following  there  has 
usually  been  retention  of  urine,  and  after  this  incontinence.  It  is  rare  that  a 
leakage  occurs  directly  after  the  delivery,  indicating  that  a  rupture  of  the 
bladder  has  taken  place  at  that  time.  In  most  instances  the  bladder  wall 
is  crushed  only  sufficient  to  become  gangrenous  after  a  time,  but  will 
support  the  urine  for  several  days  after  the  confinement. 

Prophylaxis. 

At  this  point  it  might  be  well  to  state  that  in  these  cases  the  formation 
of  the  fistula  might  frequently  be  prevented  if,  directly  after  a  delivery  in 
which  an  unusual  amount  of  pressure  occurred,  the  conditions  were  made 
favorable  for  the  restoration  of  the  normal  vitality  of  the  crushed  tissues. 
This  would  be  greatly  assisted  by  the  introduction  of  the  retention  catheter, 
which  would  keep  the  bladder  constantly  empty  and  consequently  improve 
the  circulatory  conditions  in  this  organ  by  removing  the  intra-vesical  pres- 
sure. If,  however,  a  portion  of  the  posterior  bladder  wall  and  the  anterior 
vaginal  wall  have  sloughed  away  so  that  a  vesico-vaginal  fistula  has  oc- 
curred nearly  at  the  time  at  which  the  patient  comes  under  treatment,  re- 
lief must  come  from  a  reparatory  operation,  unless  the  fistula  be  very  small, 
in  which  case  simple  continuous  drainage  of  the  bladder  will  result  in  a 
healing  of  the  opening. 

Technique. 

If  the  fistula  be  moderate  in  size  it  is  necessary  only  to  bring  in  coapta- 
tion  relatively  broad  surfaces  in  order  to  secure  a  closure  of  the  aperture. 
This  can  be  accomplished  by  splitting  the  edge  of  the  fistula  in  its  entire 
circumference,  then  applying  a  row  of  fine  cat-gut  sutures  to  the  mucous 
membrane,  in  order  not  to  permit  any  portion  of  the  suture  to  project  into 
the  bladder.  A  second  row  of  sutures  is  applied  to  the  connective  tissue 
layer  between  the  vesical  and  the  vaginal  mucous  membrane.  A  third  row 
of  sutures  is  then  applied  to  the  vaginal  mucous  membrane.  The  bladder 
is  then  drained  with  a  retention  catheter  and  the  after-treatment  carried  out 
as  described  in  the  operation  of  vesicocele. 


82O  SURGERY    OF    THE    FEMALE    PELVIS 

Prognosis. 

If  the  fistula  be  moderate  in  size  the  prognosis  is  almost  invariably 
good.  If,  however,  it  is  large  the  closure  must  be  accomplished  by  plastic 
operations,  portions  of  the  mucous  membrane  being  taken  from  various  parts 
apparently  most  suited  for  that  purpose,  but  if  the  entire  posterior  wall  of 
the  bladder  has  been  destroyed  its  repair  will  require  a  great  amount  of 
skill  in  plastic  surgery. 

RECTO-VAGINAL  FISTULA. 

This  condition  is  produced  either  by  the  opening  of  an  abscess  in  the 
recto-vaginal  septum  into  both  the  vagina  and  the  rectum  simultaneously,  or 
by  the  causes  which  have  been  mentioned  in  connection  with  vesico-vaginal 
fistula.  The  operation  for  its  relief  is  virtually  the  same  as  that  for  vesico- 
vaginal  fistula,  with  the  addition  of  a  very  thorough  dilatation  of  the 
sphincter  ani  muscles  so  as  to  prevent  pressure  of  the  wound  from  the 
side  of  the  rectum  due  to  the  retention  of  fecal  material  on  account  of  a 
tightly  constricted  sphincter.  The  after-treatment  in  these  cases  is  the 
same  as  that  just  described. 

CYSTS  OF  BARTHOLIN'S  GLANDS. 

The  occlusion  of  the  ducts  of  Bartholin's  glands,  causing  cysts,  is  of 
rather  common  occurrence,  and  the  result  of  such  occlusion  is  the  same  as 
of  the  ducts  of  other  glands.  An  accumulation  of  the  mucous  secreted  by 
the  gland  occurs  within  the  ducts,  causing  a  distension  which  may  increase 
to  such  an  extent  as  to  give  rise  to  great  inconvenience  and  sometimes  to 
pain.  The  location  of  these  cysts  makes  their  infection  quite  likely,  and  con- 
sequently suppurating  cysts  of  the  glands  of  Bartholin  is  not  an  uncom- 
mon complication.  This  is  especially  true  of  patients  who  have  suffered  from 
gonorrheal  infection.  These  suppurating  cysts  may  open  spontaneously, 
and  this  may  result  in  a  spontaneous  cure  or  in  the  formation  of  a  fistula  or 
recurrent  abscesses. 

Treatment. 

The  treatment  may  consist  in  a  simple  puncture  of  the  cyst,  but  this  will 
usually  result  only  in  temporary  benefit,  and  is  consequently  unjustifiable, 
except  where  the  patient  must  have  immediate  relief  and  cannot  possibly 
subject  herself  to  a  radical  operation,  consisting  in  the  excision  of  the  entire 
cyst.  For  permanent  relief  an  incision  is  made  over  the  most  prominent 
portion  of  the  cyst,  which  is  then  dissected  out  from  the  surrounding  tis- 
sues. With  care  it  is  possible  to  obtain  the  line  of  cleavage  between  the 
cyst  wall  and  the  surrounding  tissues,  and  with  a  careful  dissection  the  en- 
tire tumor  can  usually  be  excised  without  rupture.  The  space  occupied  by 
the  cyst  is  then  closed  by  means  of  a  few  buried  sutures  of  cat-gut  and  a 
row  of  sutures  uniting  the  mucous  membrane,  and  the  ordinary  dressing 
applied. 

DYSMENORRHEA  DUE  TO  ATRESIA  OF  THE  CERVIX. 

In  by  far  the  greater  number  of  patients  suffering  from  dysmenorrhea 
the  cause  lies  in  the  results  of  inflammatory  conditions  above  the  uterus.  In 
considering  appendicitis  this  subject  was  discussed,  and  again  in  speaking 


SURGERY    OF    THE    FEMALE    PELVIS  821 

of  pyosalpinx,  but  there  is  a  certain  number  of  cases  in  which  none  of  the 
inflammatory  conditions  affecting  the  tubes  and  ovaries  are  present  and  in 
which  the  cause  of  the  dysmenorrhea  lies  in  an  atresia  of  the  cervix,  or  in 
a  mechanical  obstruction  due  to  a  short  bend  of  the  body  of  the  uterus  upon 
the  cervix,  or  in  an  inflammatory  condition  of  the  mucous  lining  of  the 
uterus  and  cervix.  In  these  patients  the  trouble  may  be  relieved  by  thorough 
dilatation  of  the  cervix,  repeated  a  number  of  times.  The  dilatation  may 
best  be  started  by  inserting  ordinary  male  urethral  steel  sounds,  beginning 
with  a  size  sufficiently  small  to  enter  the  contracted  cervix  and  increasing 
gradually  until  the  largest  size  is  reached ;  then  introducing  a  uterine  dilator 
and  stretching  the  cervix  as  much  as  it  will  bear  without  tearing.  The  dilator 
should  be  left  in  position  under  tension,  then  relaxed,  then  dilated  again — 
and  this  repeated  many  times  until  the  canal  remains  comparatively  wide 
open  after  the  dilator  has  been  removed.  If  there  is  a  sharp  angle  between 
the  cervix  and  the  uterus  it  is  well  to  dilate  the  cervix  as  much  as  possible 
without  causing  any  laceration,  and  then  insert  a  tenotome  and  transversely 
cut  the  ridge  opposite  the  junction  between  the  body  of  the  uterus  and  the 
cervix.  In  case  there  has  been  an  endometritis  which  has  resulted  in  the 
formation  of  granulation  tissue  within  the  uterus  and  the  cervical  canal 
this  should  be  thoroughly  curetted  away  with  a  moderately  blunt  curette 
and  then  sponged  with  aseptic  gauze.  The  uterine  cavity  should  afterwards 
be  tamponed  with  a  piece  of  aseptic  gauze  moistened  with  ninety-five  per 
cent  solution  of  carbolic  acid.  This  should  be  left  in  place  from  two  to  five 
minutes  and  then  withdrawn.  Then  the  cavity  should  be  tamponed  with 
a  piece  of  gauze  saturated  with  strong  alcohol.  After  this  has  been  removed 
a  piece  of  iodoform  gauze  may  be  carried  up  into  the  uterus  in  order  to 
serve  as  a  capillary  drain.  More  recently  we  have  invariably  tamponed 
the  uterus  with  gauze  saturated  with  Beck's  bismuth  paste.  This  tampon 
is  left  in  position  for  from  two  to  three  days. 

After-treatment. 

The  patient  should  be  kept  in  bed  for  from  one  to  two  weeks  and 
receive  from  three  to  six  large,  hot  douches  every  day,  in  order  to  relieve 
the  congestion  resulting  from  the  operation.  During  the  subsequent  men- 
strual periods  the  patient  should  receive  a  mild  uterine  sedative  during 
each  period  for  a  number  of  months.  Patients  suffering  from  this  condition 
are  likely  to  expect  pain,  and  unless  some  sedative  is  given  a  slight  amount 
of  pain  may  be  exaggerated  by  their  nervous  condition  into  a  serious  degree 
of  suffering.  On  the  contrary,  if  a  uterine  sedative  is  given,  the  patient 
will  be  entirely  free  from  distress  and  consequently  soon  cease  looking  for 
pain  during  these  periods. 

The  prognosis  will  depend  upon  the  cause  of  the  dysmenorrhea.  If 
the  cause  was  entirely  in  the  cervix  and  in  the  uterus  a  very  satisfactory 
result  may  be  expected.  If.  however,  it  was  in  the  tubes  and  ovaries,  then 
the  result  will  be  entirely  negative. 


PART   X. 


SURGERY  OF  THE  EXTREMITIES. 

OPERATIONS  FOR  THE  RELIEF  OF  FRACTURES. 

The  scope  of  this  work  does  not  comprehend  the  treatment  of  frac- 
tures, except  those  in  which  operative  interference  is  indicated.  At  the 
outset  we  wish  to  state  that  operative  intervention  is  not  indicated  in  any 
form  of  fracture  unless  the  operator  absolutely  controls  the  conditions  of 
asepsis  during  the  operation,  because  an  infection  is  so  much  more  serious 
than  the  fracture  itself  that  if  this  cannot  be  absolutely  eliminated  an  in- 
cisional  operation  is,  of  course,  not  indicated. 

FRACTURE  OF  THE  PATELLA. 

If  the  surgeon  thoroughly  controls  the  situation  so  that  he  can  be  cer- 
tain of  asepsis,  then  in  cases  of  fracture  of  the  patella  we  believe  the  op- 
erative method  is  always  indicated,  as  with  it  the  patient  may  be  out  of 
bed  in  less  than  one  week,  he  may  walk  about  comfortably  in  three  weeks, 
and  in  from  six  to' eight  weeks  he  should  be  able  to  follow  any  occupation 
he  may  have  had  at  the  time  of  injury;  while  without  such  operative  treat- 
ment he  will  be  disabled  for  many  months  at  best. 

The  following  case  may  illustrate :  A  young  man,  forty  years  of  age, 
fell  upon  his  right  patella  and  fractured  it.  He  had  it  treated  by  means 
of  splints  and  strapping,  and  obtained  a  very  satisfactory  result,  which  en- 
abled him  to  pursue  his  occupation  of  book-keeper  in  a  large  establishment 
at  the  end  of  six  months;  the  knee,  however,  never  became  thoroughly 
strong,  so  that  the  patient  could  not  take  long  walks  without  becoming  ex- 
hausted. Two  years  later  he  fell  upon  the  other  knee  and  fractured  the 
patella  in  the  same  manner.  An  open  operation  was  at  once  performed  and 
the  extremity  placed  in  a  plaster  of  Paris  cast.  At  the  end  of  one  week 
the  patient  was  allowed  to  be  out  of  bed.  At  the  end  of  three  weeks  he 
was  able  to  resume  work  in  the  office,  continuing,  however,  to  wear  a  cast. 
At  the  end  of  eight  weeks  his  left  leg  was  in  a  much  better  condition  than 
his  right,  which  had  been  injured  two  and  one-half  years  before. 

"\Ye  have  had  numerous  opportunities  of  making  similar  comparisons 
in  fractures  of  the  patella  taking  place  in  different  persons  at  the  same  time, 
and  are  convinced  that  with  a  clean  operator  an  open  method  is  as  safe  as 
the  treatment  with  splints,  and  has  all  the  other  advantages  just  mentioned. 
Technique. 

A  transverse,  curved  incision  is  made  with  its  center  three  centimeters 
below  the  point  of  the  fracture  of  the  patella.  This  flap  is  turned  up;  the 
blood  clots  found  to  be  present  are  sponged  away  with  moist  aseptic  gauze 
pads  ;  the  two  fragments  are  then  placed  in  accurate  apposition ;  and  the 


824  SURGERY    OF    THE    EXTREMITIES 

capsule  to  each  side  of  the  fracture  is  sutured  by  means  of  chromicized  cat- 
gut, which  will  last  about  two  weeks.  A  few  superficial  sutures  are  then 
applied  to  hold  the  patella  in  accurate  apposition,  and  the  skin  sutured  over 
all.  A  small  plaster  of  Paris  cast  is  then  applied  and  the  patient  placed  in 
bed,  with  the  extremity  elevated.  It  is  important  that  the  extremity  should 
be  elevated,  because'  this  relaxes  the  quadriceps  femoris  muscle  and  conse- 
quently prevents  pulling  upon  the  upper  fragment. 

After  six  or  eight  days  the  patient  is  permitted  to  sit  up  out  of  bed, 
and  after  three  weeks  he  is  allowed  to  walk,  with  a  cast  upon  the  extremity. 
Five  or  six  weeks  after  the  operation  the  cast  is  removed  and  the  patient 
permitted  to  walk  with  a  cane.  It  is  neither  necessary  nor  desirable  that 
the  patient  should  walk  with  a  crutch  at  any  time.  In  case  there  should  be 
a  certain  amount  of  limitation  of  motion  in  the  knee  after  recovering  from 
this  operation,  which,  in  our  experience,  has  been  very  rare,  this  can  be 
overcome  most  readily  by  having  the  patient  ride  a  bicycle,  or  a  tricycle  if 
he  is  not  accustomed  to  the  former.  The  result  is  so  much  better  after 
this  treatment  than  after  the  methods  ordinarily  in  vogue  that  we  believe 
it  should  become  a  recognized  method,  only,  however,  in  the  hands  of  clean 
surgeons. 

FRACTURE  OF  THE  OLECRANON. 

The  recovery  from  a  fracture  of  the  olecranon  is  ordinarily  so  much 
easier,  and  the  conditions  after  healing  are  so  perfect  if  the  fragments  are 
applied  by  the  use  of  catgut  sutures,  that  here  also  an  operation  is  indi- 
cated. 

Technique. 

A  longitudinal  incision  is  made  directly  over  the  middle  line  of  the 
olecranon  process  and  the  soft  tissues  are  carefully  retracted  in  order  to 
avoid  injuring  the  ulnar  nerve.  It  is  important  at  this  point  for  the  sur- 
geon to  bear  in  mind  the  relative  position  of  the  olecranon  and  the  ulnar 
nerve,  as  if  the  operation  is  performed  with  the  hand  in  the  position  of  pro- 
nation  the  surgeon  may  be  confused  by  the  fact  that  ordinarily  we  carry 
the  relations  in  our  mind  with  the  hand  in  the  position  of  supination.  The 
nerve  mentioned  passes  between  the  internal  condyle  and  the  olecranon,  but 
when  the  hand  is  pronated  so  as  to  place  the  olecranon  in  a  convenient  po- 
sition for  operation,  then  the  internal  condyle  is  turned  to  the  outer  side. 
If  this  fact  is  borne  in  mind  the  nerve  may  be  very  easily  avoided.  Here, 
again,  the  fragments  of  bone  are  united  by  means  of  chomicized  catgut, 
which  will  last  about  fifteen  days.  In  case  a  sufficiently  firm  hold  can  be 
obtained  by  passing  these  sutures  through  the  periosteum  and  the  surround- 
ing soft  tissues  to  retain  the  fragments  in  perfect  juxtaposition  that  is  all 
that  will,  be  required.  If  this  cannot  be  done  a  small  opening  should  be 
drilled  through  the  middle  of  the  olecranon  process  and  through  the  upper 
end  of  the  ulna,  and  a  suture  passed  through  this.  The  arm  should  be 
dressed  in  the  extended  position  by  means  of  a  plaster  of  Paris  cast. 

FRACTURE  OF  THE  ACROMION  PROCESS. 

In  fracture  of  the  acromion  process,  in  which  it  is  found  difficult  to 
maintain  the  proper  position,  an  incision  should  be  made  parallel  with  the 
spine  of  the  scapula,  the  fracture  should  be  exposed  with  as  little  dis- 


SURGERY    OF    THE    EXTREMITIES  825 

turbance  of  the  soft  tissues  as  possible,  and  the  fractured  end  sutured 
in  place,  if  possible,  by  passing  the  sutures  through  the  soft 
tissues.  If  it  is  not  possible  to  firmly  adjust  the  fragments  in  this  man- 
ner small  openings  should  be  drilled  into  the  end  of  each  fragment  and  at 
least  two  chromicized  catgut  sutures  applied  in  order  to  secure  a  perfect  co- 
aptation. 

FRACTURES  OF  THE  OUTER  END  OF  THE  CLAVICLE. 

In  very  rare  instances  a  fracture  occurs  near  the  outer  extremity  of 
the  clavicle  which  cannot  be  retained  in  any  reasonable  position  by  means 
of  dressings  ordinarily  used  for  this  purpose.  In  such  case  the  most  su- 
perficial portion  of  the  bone  should  be  sought,  namely,  upon  the  line  be- 
tween the  attachment  of  the  trapezius  muscle  and  the  deltoid,  and  an  in- 
cision at  this  point  should  expose  the  fracture,  which  can  then  be  readily 
adjusted  by  means  of  a  few  catgut  sutures.  After  these  have  been  applied 
the  skin  is  sutured  and  a  rubber  adhesive  plaster  applied  upward  from  the 
chest,  covering  both  fragments  and  extending  backward  over  the  scapula. 
The  arm  is  then  placed  in  a  sling  and  carried  in  this  poistion  for  a  period  of 
three  to  six  weeks. 

In  these  cases  we  now  invariably  use  the  Lane  plates  because  they  hold 
the  ends  in  absolute  coaptation  and  produce  ideal  results. 

In  the  same  region  occasionally  a  severe  traumatism  causes  a  disloca- 
tion of  the  outer  end  of  the  clavicle,  loosening  its  attachment  to  the  acro- 
mion  process  of  the  scapula,  the  acromio-clavicular  ligaments  being  com- 
pletely lacerated.  Ordinarily  this  dislocation  can  be  reduced  by  means  of 
properly  applied  rubber  adhesive  straps,  but  if  such  a  result  is  found  im- 
possible then  the  incision  which  has  just  been  described  for  the  treatment 
of  a  fracture  at  the  outer  end  of  the  clavicle  should  be  made,  the  dislo- 
cation reduced,  and  the  ruptured  acromio-clavicular  ligaments  carefully 
sutured  with  chromicized  catgut.  The  dressing  just  described  in  connection 
with  the  rubber  adhesive  plaster  dressing  should  be  applied  and  a  second 
broad  strap  of  rubber  adhesive  plaster  adjusted  as  follows :  Beginning 
about  the  angle  of  the  eighth  or  tenth  rib  the  plaster  is  passed  upwards  and 
outwards,  so  that  its  middle  portion  strikes  the  end  of  the  clavicle.  It  is 
then  carried  forwards  and  downwards  and  passed  around  the  forearm  four 
centimeters  below  the  end  of  the  olecranon  process  with  the  arm  in  the 
flexed  position.  In  this  manner  the  leverage  of  the  arm  upon  the  adhesive 
plaster  straps  serves  to  hold  down  the  end  of  the  clavicle  in  position  and 
relieves  the  tension  upon  the  chromicized  catgut  sutures. 

EPIPHYSEAL  FRACTURES. 

In  epiphyseal  fractures  in  any  portion  of  the  skeleton  in  which,  after 
careful  manipulation  under  anesthesia,  it  is  found  impossible  to  adjust  the 
fragments,  it  is  desirable  to  resort  to  an  open  operation  at  once — always 
providing  that  the  surgeon  completely  controls  the  conditions  of  asepsis. 
The  deformities  which  occur  after  these  fractures  are  unusually  annoying, 
because  of  their  proximity  to  the  joints.  This  fact,  of  course,  makes  the 
open  operation  more  hazardous,  but  the  benefits  of  the  operation  are  so 
great  in  cases  in  which,  after  careful  trial,  it  has  been  found  impossible  to 
adjust  the  fragments,  that  the  surgeon  is  justified  in  taking  the  additional 


826  SURGERY    OF    THE    EXTREMITIES 

risk.  Where  the  fractures  have  not  been  adjusted  there  will  be  found  a 
retardation  of  growth  from  the  epiphyseal  line  involved,  aside  from  the 
deformity.  Whether  this  can  always  be  avoided  by  an  open  operation  it  is 
impossible  to  say  with  the  relatively  small  amount  of  clinical  observation 
upon  this  subject,  but  in  cases  in  which  the  operation  has  been  done  the  re- 
sults have  been  much  more  satisfactory  than  in  those  in  which  the  irreducible 
deformity  has  been  permitted  to  persist. 

COMPOUND  FRACTURES. 

In  compound  fractures  the  most  important  point  to  be  considered  is 
the  production  of  conditions  as  nearly  as  possible  like  those  in  simple  frac- 
tures. These  conditions  may  be  secured  most  readily  by  laying  the  wound 
open  sufficiently  to  remove  the  extraneous  matter  which  may  have  been 
forced  into  it  at  the  time  of  the  injury,  or  by  the  manipulations  which  oc- 
curred before  the  patient  entered  the  hands  of  the  surgeon.  After  the 
wound  has  been  carefully  disinfected  and  all  of  the  entirely  loose  frag- 
ments removed,  those  which  have  some  attachment  to  the  periosteum  being 
carefully  adjusted,  the  fragments  should  be  placed  in  as  nearly  a  normal 
position  as  possible,  and  if  it  seems  likely  that  this  position  can  be  main- 
tained by  the  use  of  external  splints,  then  it  seems  proper  that  such  external 
splints  be  applied.  If,  however,  it  is  clear  that  this  position  of  the  frag- 
ments cannot  be  maintained  then  the  same  should  be  sutured  in  place  by 
means  of  catgut  sutures. 

In  our  own  practice  we  have  for  a  number  of  years  applied  strong 
tincture  of  iodine  to  all  of  the  injured  tissues  involved  in  compound  frac- 
tures, and  have  then  applied  strands  of  iocloform  gauze  down  to  the  point 
of  fracture,  permitting  them  to  project  from  the  outer  wound.  This  has 
been  done  because  it  has  been  claimed  by  good  authorities  that  in  the 
presence  of  iodine,  and  especially  iocloform,  the  development  of  the  tetanus 
bacillus  is  much  less  likely  than  under  any  other  form  of  treatment.  Per- 
sonally, we  are  well  satisfied  with  this  method,  being  careful,  however,  to 
thoroughly  cleanse  the  surfaces  with  large  quantities  of  hot  water  and 
with  a  i  :2,ooo  solution  of  corrosive  sublimate.  Other  surgeons  have  equal- 
ly satisfactory  results  with  other  methods,  and  consequently  we  do  not  feel 
justified  in  giving  this  as  one  which  should  be  generally  adopted  as  being 
better  than  any  other.  The  dressings  should  be  applied  so  that  they  may 
be  removed  without  disturbing  the  relation  of  the  fractured  ends. 

OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES. 

During  the  past  year  it  has  been  the  practice  of  the  authors  to  operate 
upon  all  simple  fractures  of  long  bones  in  which  we  were  unable  to  restore 
the  normal  relationship  of  the  fragments  by  ordinary  means,  and  in  laboring 
people  in  whom  it  was  important  that  their  mechanics  should  not  be  impaired. 
In  these  cases  we  have  used  the  method  of  Mr.  Lane,  of  London,  which 
consists  in  the  application  of  steel  plates  to  keep  the  fragments  in  place. 
During  the  past  eight  months  we  have  applied  the  plates  in  thirty  cases  with 
excellent  immediate  results  in  all.  We  have  found  that  this  method  of 
treatment  in  simple  fractures  possesses  all  of  the  advantages  to  the  patient, 
claimed  for  it  bv  Mr.  Lane,  which  are  as  follows: 


SURGERY    OF    THE    EXTREMITIES  827 

(A)  The  patient  is  at  once  relieved  of  the  pain  of  any  movement  of 
the  fragments  upon  one  another. 

(B)  He  is  freed  from  the  tension  and  discomfort  due  to  the  extensive 
extravasation  of  blood  between  and  into  the  tissues. 

(C)  It  shortens  the  duration  of  the  period  during  which  he  is  incapaci- 
tated  from  work,   since  union  is  practically  by  first  intention,   and  conse- 
quently very  rapid  and  perfect. 

(D)  Lastly,  and  by  far  the  most  important,  they  leave  the  skeletal 
mechanics  in  the  condition  in  which  they  were  before  the  sustained  injury. 

This  treatment  is  especially  indicated  in  fractures  of  the  shaft  of  the 
humerus  and  the  femur,  for  in  the  majority  of  cases  one  cannot  hold  the 
fragments  in  accurate  apposition  with  any  degree  of  certainty  without  opera- 
tive measures. 

This  method  of  treatment  should  not  be  used  except  in  a  well-regulated 
hospital  where  the  surgeon  can  be  absolutely  certain  that  every  detail  of 
the  operation  will  be  carried  on  in  an  aseptic  manner.  It  is  obvious  that 
where  a  considerable  quantity  of  metal  is  to  be  left  in  a  wound,  it  is  neces- 
sary that  greater  aseptic  precautions  must  be  taken  than  in  ordinary  opera- 
tions where  foreign  bodies  are  not  left  in  the  wound.  During  the  past 
seven  years  Mr.  Lane  has  demonstrated  in  hundreds  of  cases  that  a  fixed 
foreign  body,  when  introduced  in  a  perfectly  aseptic  state,  does  not  cause 
any  irritation  or  trouble,  and  that  screws  placed  in  the  bone  under  aseptic 
conditions  do  not  cause  a  rarefying  osteitis. 

Technique. 

The  skin  in  the  region  of  the  fracture  is  very  thoroughly  disinfected, 
and  an  incision  is  made  through  it  and  superficial  fascia  at  a  point  from 
which  the  fragments  may  be  reached  with  a  minimum  damage  to  the  soft 
parts.  The  skin  in  the  field  of  operation  should  now  be  excluded  from  the 
wound  by  attaching  sterile  gauze  pads  to  the  divided  margin  of  the  skin 
by  means  of  forceps  devised  for  this  purpose. 

The  deep  fascia  and  muscle  sheaths  are  now  severed  and  then  the 
muscles  are  separated  by  blunt  dissection  until  the  fragments  are-  reached. 
All  bleeding  points  should  be  grasped  by  rather  heavy  forceps  so  that  by 
the  time  the  operation  is  completed,  few  if  any  ligatures  will  need  to  be 
applied.  The  wound  should  be  carefully  freed  from  the  old  extravasated 
blood  so  that  fragments  may  be  inspected.  Now  by  special  bone-holding 
forceps,  which  have  long  strong  handles,  the  fragments  are  placed  in  ac- 
curate apposition  so  that  the  normal  contour  of  the  bone  is  absolutely  re- 
stored. Now  while  the  fragments  are  held  in  apposition  by  means  of  these 
forceps,  a  steel  plate  which  has  been  perforated  by  a  number  of  small  holes 
for  screws,  is  placed  across  the  line  of  fracture.  Small  holes  are  now  drilled 
into  the  bone  at  points  directly  opposite  the  holes  in  the  plate.  Small  steel 
screws  are  then  inserted  and  screwed  in  tight  by  means  of  a  strong  screw 
driver.  In  large  bones  like  the  femur  and  humerus  two  plates  are  applied 
if  possible.  The  plates  are  rigid  and  when  screwed  firm  across  the  line  of 
fracture,  they  hold  the  bone  very  definitely,  in  fact  they  do  away  with  all 
motion  between  the  fragments.  As  soon  as  the  plates  are  in  place,  the 
wound  is  closed  without  drainage,  and  a  dressing  is  applied  immobilizing 
the  extremity. 

In  applying  the  plates  thev  should  be  so  attached  as  to  not  form  a  pro- 
jection beneath  the  skin,  for  in  that  case  they  might  cause  pain  or  incon- 


828  SURGERY    OF    THE    EXTREMITIES 

venience,  making  it  necessary  to  remove  them  at  a  subsequent  date.  In 
fractures  of  the  femur  there  are  abundant  soft  parts  to  cover  and  protect 
the  plate,  but  in  some  fractures  of  the  tibia  it  is  necessary  to  place  the  plate 
subcutaneously.  Under  such  circumstances  it  is  better  to  remove  the  plate 
as  soon  as  union  has  taken  place,  and  when  it  is  of  no  further  use. 

In  all  of  our  patients  convalesence  has  been  rapid,  primary  union  has 
taken  place,  and  there  has  been  complete  absence  of  pain  following  the 
operation. 

UNUNITED   FRACTURES. 

In  the  treatment  of  a  large  number  of  ununited  fractures  we  have 
invariably  found  that  the  ends  of  the  fragments  were  separated  by  some 
intervening  fascia,  muscle  or  cicatricial  tissue.  These  cases  are  almost 
always  in  patients  who  have  sustained  an  exceedingly  violent  injury,  so 
.'hat  the  ends  of  the  bones  have  been  forced  beyond  each  other  with  great 
energy. 

Prophylaxis. 

In  many  instances  during  the  original  reduction  of  the  fracture  one 
observes  the  fact  that  after  the  fracture  has  apparently  been  corrected,  the 
moment  the  surgeon's  grasp  upon  the  extremity  is  loosened  a  marked  de- 
formity occurs  and  that  the  ends  of  the  bones  show  no  tendency  to  become 
engaged  against  each  other.  This  condition  is,  we  believe,  frequently  an 
indication  that  one  or  the  other  end  of  the  bone  has  been  forced  through 
some  of  the  surrounding  soft  tissues,  and  that  the  moment  tension  upon 
the  extremity  is  relaxed  this  soft  tissue  causes  the  fragments  to  slip  past 
each  other.  If  this  point  is  regarded  and  overcome  during  the  reduction 
of  fracture  it  is  believed  many  cases  of  non-union  may  be  avoided.  The 
soft  tissues  are  usually  forced  in  between  the  ends  of  the  fractures  at  the 
time  of  the  injury,  except  in  cases  of  compound  fracture  in  which  a  con- 
siderable portion  of  bone  is  entirely  lost,  leaving  only  soft  tissues  between 
the  two  fragments. 

Cases  of  non-union  should  be  treated  by  open  operation.  An  incision 
is  made  at  some  point  at  which  the  bone  can  be  approached  without  inter- 
fering with  any  important  anatomical  structures.  The  soft  tissues  between 
the  ends  of  the  fractured  bone  are  thus  completely  dissected  away,  so  that 
the  ends  of  the  bone  are  free  with  the  exception  of  the  connective  tissue 
which  has  formed  over  these  ends.  This  connective  tissue  is  then  cut  away 
by  means  of  a  sharp  carpenter's  chisel.  Frequently  the  ends  of  the  bone 
have  become  rounded,  if  this  condition  is  present  such  ends  should  be  cut 
off  for  a  short  distance  by  means  of  a  saw  or  chisel,  so  that  the  fragments 
may  be  placed  in  perfect  apposition.  The  fragments  arc  now  held  in  contact 
by  screwing  on  to  the  side  of  the  bone  two  steel  plates,  the  technique  of 
which  is  described  under  the  operative  treatment  of  simple  fractures.  These 
plates  give  rigidity  to  the  bone  and  keep  the  fragments  in  absolute  contact 
with  each  other,  with  the  result  that  union  usually  takes  place  in  a  short 
time. 

Clinical  History. 

Patient  forty-five  years  of  age.  a  machinist  by  trade.  Family  history 
very  good.  Personal  history  good,  in  fact  patient  had  never  been  sick  until 
time  of  accident,  eleven  years  ago,  when  he  was  kicked  by  a  horse  on  the 


PLATE  CLII. 

X  Hay  of  an  ununited  fracture  of  the  humerus  of  ten  years'  standing.  Elbow  is 
at  angle  of  90°  and  the  lower  fragment  of  humerus  is  at  right  angle  to  shaft  of 
humerus. 


PLATE  CLIII. 
Same  case  as  shown  in  Plate  CLII,  showing  Lane  plate  in  place. 


SURGERY    OF    THE    EXTREMITIES  833 

right  arm,  which  produced  a  compound,  comminuted  fracture  of  the  right 
humerus  at  junction  of  lower  and  middle  third.  Wound  became  infected  and 
patient  remained  in  hospital  for  a  period  of  twenty-two  months,  during 
which  time  he  underwent  four  surgical  operations,  some  pieces  of  bone  being 
removed  each  time. 

At  the  time  of  leaving  hospital,  wound  was  completely  healed,  but  there 
was  no  union  of  the  two  fragments  of  the  humerus.  One  year  later  patient 
was  operated  upon  for  the  non-union.  The  ends  of  the  bone  were  freshened 
and  fastened  together  by  means  of  silver  wire.  Again  the  bone  did  not  unite 
and  the  wire  had  to  be  removed  a  few  months  later  because  of  irritation. 
Two  years  later  a  second  operation  was  performed,  the  ends  of  the  frag- 
ments freshened  and  again  fastened  with  silver  wire,  the  result  being  the 
same  as  before.  Two  more  attempts  were  made  in  the  same  manner  to 
secure  union,  but  the  result  was  the  same  each  time.  The  last  operation 
was  performed  three  years  ago.  Four  years  ago  received  a  bullet  wound 
in  left  thigh.  The  bullet  was  not  removed  and  has  never  caused  any  trouble. 
During  past  two  years  patient  troubled  some  with  belching  of  gas  and 
some  distress  in  epigastrium  after  eating,  otherwise  well  until  up  to  the 
present  time.  Patient  comes  complaining  of  a  false  joint  in  right  arm  at 
a  point  about  three  inches  above  the  elbow  joint. 
Examination. 

Patient  is  well  nourished,  tongue  coated,  appetite  good,  bowels  regular, 
chest  is  negative,  abdomen  negative. 

Arm. 

Distance  from  right  acromion  process  to  olecranon  process  is  1^/2 
inches.  Distance  from  left  acromion  process  to  left  olecranon  process  is  17 
inches.  Considerable  atrophy  of  muscles  of  right  arm,  but  muscles  of  right 
forearm  are  about  normal.  Patient  had  good  use  of  forearm,  the  false 
joint  in  the  humerus  acting  as  the  elbow  joint.  The  false  joint  in  the 
humerus  was  ten  inches  distant  from  the  right  acromion  process.  The  lower 
fragment  of  the  humerus  which  was  about  3Ti  inches  long  remained  at 
right  angles  to  the  bones  of  the  forearm.  By  grasping  this  fragment  firmly 
and  moving  the  forearm  it  was  found  that  there  was  about  twenty  degrees 
motion  in  the  elbow  joint.  When  the  forearm  was  extended  the  lower  frag- 
ment assumed  a  transverse  position  to  the  long  axis  of  the  humerus  as 
shown  in  Plate  (TJI. 

Technique. 

Patient  was  anesthetized  and  an  incision  made  on  the  outer  surface 
of  right  arm  on  the  false  joint.  The  musculo-spiral  nerve  was  exposed  early 
in  the  dissection.  It  was  markedly  enlarged  and  imbedded  in  connective 
tissue  in  the  region  of  the  false  joint.  The  nerve  was  dissected  free  and 
retracted.  All  of  the  connective  tissue  was  dissected  away,  the  ends  of 
the  bone  were  freshened  by  sawing  off  the  rounded  ends,  the  two  fragments 
approximated  and  held  in  apposition  by  screwing  two  steel  plates  on  the 
humerns.  This  was  accomplished  with  considerable  difficulty  on  account 
of  the  shortness  of  the  lower  fragment  and  the  limited  motion  in  the  elbow 
joint.  It  was  necessary  to  place  the  forearm  at  right  angles  to  the  arm  in 
order  to  bring  the  fragments  in  juxtaposition,  making  it  rather  difficult  to 
apply  the  plates  to  the  short  lower  fragment.  After  the  pk'tes  were  applied, 
the  wound  was  closed  and  a  cast  applied  with  forearm  at  right  angles  to 
arm.  Plate  CLTII  shows  the  arm  with  plates  in  place. 


834  SURGERY    OF    THE    EXTREMITIES 

Cast  was  removed  at  end  of  twelve  weeks  at  which  time  the  bone  seemed 
to  be  very  firm.  The  arm  was  left  without  a  cast  and  was  examined  again 
in  a  week.  At  this  time  union  seemed  very  firm,  there  was  absolutely  no 
pain  or  tenderness  and  there  was  about  thirty  degrees  of  motion  in  the 
elbow  joint. 

OSTEOMYELITIS. 

Patients  suffering  from  acute  osteomyelitis  usually  give  a  history  of  a 
sudden  attack  of  pain,  most  frequently  at  the  point  of  entrance  of  the 
nutrient  artery  or  near  one  of  the  epiphyseal  extremities  of  one  of  the  long 
bones.  This  attack  usually  occurs  after  exposure  to  wet  and  cold. 

In  many  cases  it  is  possible  to  trace  a  history  of  follicular  tonsillitis  as 
the  source  of  the  infection.  The  pain  is  extreme  upon  pressure  and  most 
extreme  early  in  the  disease  at  one  particular  circumscribed  point.  The 
patient  has  high  fever  and  feels  thoroughly  ill,  having  the  general  appear- 
ance of  one  suffering  from  acute  sepsis.  The  pain  becomes  more  and 
more  diffuse  and  the  extremity  becomes  swollen  and  later  on  edematous 
and  reddened,  and  ultimately  fluctuation  will  appear.  In  a  very  large  pro- 
portion of  these  cases  the  early  diagnosis  is  that  of  localized  rheumatism, 
and,  vice  versa,  conditions  giving  rise  to  a  diagnosis  of  localized  rheuma- 
tism near  the  center  of  a  long  bone,  or  near  one  of  the  epiphyseal  lines, 
practically  always  means  that  the  patient  is  suffering  from  acute  osteo- 
myelitis. In  many  the  disease  seems  to  have  been  located  by  a  slight  trau- 
matism.  Of  course,  it  is  always  necessary  to  bear  in  mind  that  the  osteo- 
myelitis may  have  existed  and  that  the  traumatism  was  but  a  coincidence. 
Technique. 

It  is  necessary  only  to  bear  in  mind  the  pathological  conditions  pres- 
ent in  order  to  determine  the  proper  treatment.  There  is  a  violent  circum- 
scribed infection  which,  if  left  undisturbed,  is  certain  to  progress  along  the 
blood  vessels  and  lymph  channels  and  become  more  and  more  diffuse.  The 
bone  is  surrounded  by  a  tense  membrane,  the  periosteum,  and  consequently 
the  products  of  the  infection  cannot  easily  escape,  and  the  pressure  caused 
by  these  against  the  sensitive  periosteum  gives  rise  to  the  excruciating  pain. 
It  is  plain,  then,  that  in  order  to  secure  relief  from  pain  conditions  must  be 
established  providing  for  the  escape  of  the  products  of  infection  confined 
within  the  periosteum.  This  may  be  accomplished  most  readily  by  making 
a  long  incision  through  all  of  the  tissues  down  through  the  periosteum. 
Such  treatment  at  once  permits  the  septic  material  to  escape,  it  relieves  the 
pressure,  stops  the  pain,  and  directs  the  lymph  stream  away  from  the 
body  and  therefore  prevents  the  progress  of  the  infection. 

A  number  of  years  ago  many  excellent  surgeons  at  once  removed  the  in- 
fected bone.  In  some  instances  the  entire  shaft  of  one  of  the  long  bones  was 
found  diseased  and  entirely  removed,  and  it  seemed  as  though  this  was  the 
only  logical  way  of  treating  so  intense  an  infection.  However,  experience 
has  taught  that  in  these  cases  in  which  large  portions  of  bone  in  acute  osteo- 
myelitis were  removed  there  was  no  reproduction  of  new  bone  to  take  the 
place  of  that  removed,  and  consequently  the  extremity  was  left  without 
bony  support.  On  the  other  hand,  it  was  found  that  if  the  periosteum  was 
simply  split  open  the  recovery  was  exceedingly  rapid  from  the  acute  at- 
tack, and  many  times  a  bone  which  seemed  entirely  lost  regained  its  vitality 
and  continued  to  perform  its  physiological  functions,  while  in  other  in- 


SURGERY  OF  THE  EXTREMITIES  835 

stances  a  bone  which  seemed  entirely  destroyed  regained  its  vitality  to  a 
great  extent  and  it  was  later  necessary  to  remove  only  a  small  portion  of 
necrotic  osseous  tissue.  Again,  experience  has  taught  that  so  long  as  the 
diseased  bone  was  left  in  place  there  was  rapidly  produced  between  this 
portion  and  the  periosteum  a  layer  of  new  bone,  known  as  the  involucrum, 
which  in  a  few  months  became  strong  enough  to  substitute  the  diseased 
bone  after  this  was  removed,  and  in  such  cases  the  reproduction  of  bone 
after  the  removal  of  the  necrotic  bone  tissue  progressed  to  such  an  extent 
that  almost  the  entire  structure  was  reformed.  Moreover,  those  who  have 
frequently  operated  upon  osteomyelitic  bone  have  found  that  even  without 
the  aid  of  drainage,  resulting  from  the  incision  just  described,  almost  all 
of  these  patients  suffering  from  acute  osteomyelitis  recover  and  become 
chronic  and  that  then  it  is  possible  to  remove  the  diseased  bone  and  still 
leave  a  perfectly  useful  support  for  the  extremity  in  the  form  of  the  new 
involucrum. 

In  all  cases  of  acute  osteomyelitis,  then,  the  primary  operation  should 
consist  in  an  incision  extending  some  distance  beyond  each  end  of  the  in- 
fection in  the  bone  and  must  penetrate  all  the  tissues  down  to  the  bone,  in- 
cluding the  periosteum.  The  drainage  can  be  still  further  improved  by  the 
application  of  large,  moist  antiseptic  dressings  to  the  extremity  and,  of 
course,  complete  rest.  A  saturated  solution  of  boric  acid,  or  of  acetate  of 
aluminum,  or  a  thirty  per  cent,  solution  of  alcohol  in  hot  water,  are  most 
useful  fluids  for  this  purpose.  The  entire  extremity  should  be  enveloped  in 
this  dressing  and  covered  with  an  impervious  substance  like  oiled  silk  or 
gutta  percha  tissue,  or  an  ordinary  rubber  cloth.  Fresh  solutions  should 
be  added  three  to  six  times  a  day.  The  dressing  itself  need  not  be  removed 
more  than  once  every  two  to  four  days.  The  pain  subsides  almost  instantly, 
and  within  a  few  weeks  the  incision  usually  heals,  with  the  exception  of  a 
circumscribed  point  in  case  the  bone  does  not  entirely  recuperate. 

Only  rarely  does  the  surgeon  see  a  case  of  osteomyelitis  at  the  very 
beginning  of  the  attack,  when  the  infection  is  still  confined  to  a  limited  area 
one  or  two  centimeters  in  diameter,  which  can  be  located  because  of  the 
extreme  tenderness  in  a  particular  point.  In  these  rare  cases  the  bone 
should  be  opened  with  a  very  sharp  chisel.  The  infected  tissue  should  be 
gouged  and  scraped  out  with  great  care  and  the  cavity  filled  with  ninety- 
five  per  cent,  carbolic  acid  for  five  to  ten  minutes,  and  then  thoroughly 
washed  with  strong  alcohol.  The  skin  may  be  sutured  over  this  directly  or 
the  cavity  tamponed  for  a  few  days  and  then  sutured  secondarily. 

In  the  event  of  a  circumscribed  portion  of  bone  becoming  necrotic  it 
should  be  left  in  place  until  it  has  been  thoroughly  covered  by  an  involu- 
crum,  developed  between  the  necrotic  bone  and  the  periosteum.  After  this 
has  become  sufficiently  strong  to  support  the  extremity  it  should  be  treated 
after  the  method  to  be  described  in  connection  with  chronic  osteomyelitis 
here  following. 

CHRONIC  OSTEOMYELITIS. 

Patients  suffering  from  this  disease  most  commonly  give  a  history  of 
acute  osteomyelitis,  which  mav  have  been  treated  after  the  method  just  de- 
scribed, or,  more  frequently,  have  been  diagnosed  as  acute  localized  rheu- 
matism and  treated  accordingly.  Often  the  condition  has  progressed  to  the 
formation  of  an  abscess,  which  may  have  ruptured  spontaneously  or  been 
laid  open  by  the  surgeon.  The  sinus  resulting  from  this  abscess  refuses  to 


836  SURGERY  OF  THE  EXTREMITIES 

heal  entirely,  or  it  may  heal  and  open  from  time  to  time,  the  patient  feeling 
comparatively  comfortable  whenever  the  sinus  is  open  and  suffering  from 
pain  when  it  is  closed. 

The  infection  may  be  due  to  one  or  more  of  the  pus  microbes,  to  the 
typhoid  bacillus,  the  pneumococcus  or  to  the  bacillus  of  tuberculosis.  If 
the  latter  form  of  infection  exists  alone  the  onset  and  the  progress  of  the 
disease  is  usually  slower  than  if  due  to  any  of  the  other  micro-organisms 
mentioned. 

The  condition  must  be  differentiated  from  syphilitic  osteitis  or  perios- 
titis. The  latter  is  preceded  by  a  history  of  syphilis  or  of  hereditary  syphilis, 
or  there  may  have  been  syphilitic  infection  without  any  obtainable  history. 
The  progress  of  this  condition  is,  however,  slow  ;  it  is  characterized  by  less 
acute,  or  rather  more  deep-seated,  pain,  which  is  likely  to  be  more  severe 
at  night  than  during  the  day-time.  The  characteristic  mark  of  this  disease, 
however,  is  the  spindle-shaped  appearance  of  the  diseased  bone  and  the 
tendency  to  elongation  and  bending  of  the  bone,  in  case  the  long  bones  are 
involved,  which  is  not  very  common  except  in  the  tibia  and  occasionally  the 
femur.  Syphilis  more  commonly  attacks  the  flat  bones ;  tuberculosis  the 
joints,  the  epiphyses  and  the  short  bones ;  while  osteomyelitis  most  com- 
monly involves  the  long  bones. 

The  diagnosis  of  syphilitic  osteitis  or  periostitis  may  be  eliminated  by 
the  administration  of  Ehrlichs  remedy  606,  by  the  vigorous  use  of  mercury, 
and  by  large  doses  of  iodide  o-f  potash  continued  for  a  period  of  from  two  to 
six  weeks.  If  no  distinct  improvement  occurs  the  condition  is  probably  not 
due  to  syphilis.  Very  rarely  is  there  any  difficulty  in  making  a  differential 
diagnosis  between  osteomyelitis  and  sarcoma,  because  in  the  latter  there  is 
the  distinct  formation  of  a  tumor. 

Operative  Technique. 

The  treatment  of  chronic  osteomyelitis  consists  in  laying  bare  the  dis- 
eased bone,  reflecting  the  periosteum,  chiseling  away  a  sufficient  amount  of 
the  involucrnm  to  permit  of  the  removal  of  the  necrotic  bone ;  then  the  in- 
volucrum  should  be  chiseled  away  in  each  direction  sufficiently  to  permit  of 
the  complete  removal  of  all  infected  tissue.  The  granulations  should  be 
curetted  away  until  the  surface  of  bone  is  perfectly  smooth  and  free  from 
any  of  these  structures.  During  the  chiseling  operation  it  is  frequently 
necessary  to  employ  great  care  to  prevent  the  production  of  a  fracture,  as 
if  the  entire  shaft  of  the  bone  has  been  necrotic  the  involucrum  is  frequently 
not  strong  enough  to  bear  any  severe  strain. 

In  planning  an  operation  for  chronic  osteomyelitis  one  should,  if  pos- 
sible, arrange  to  leave  the  conditions  so  that  a  sufficient  amount  of  the 
involucrum  may  safely  be  chiseled  away  to  leave  the  space  caused  by  the 
removal  of  the  sequestrum  entirely  on  one  side  of  the  bone,  so  that  there 
will  remain  no  cavity  which  cannot  be  filled  by  the  falling  in  of  the  sur- 
rounding soft  tissues.  If,  however,  the  conditions  present  will  not  permit 
this,  the  ledge  of  bone  on  one  side  or  the  other  of  the  groove  formed  after 
the  removal  of  the  sequestrum  should  be  chiseled  parallel  to  the  bone,  re- 
maining attached,  however,  to  its  periosteum,  so  that  the  entire  ledge  may 
be  folded  in  against  the  remaining  portion  of  the  bone  which  is  continuous 
above  and  below  with  the  healthy  structure.  This  prevents  the  formation  of 
a  cavity  with  unyielding  walls  and  will  facilitate  healing  after  the  operation 
for  chronic  osteomvelitis  verv  great Iv.  After  all  of  the  diseased  tissue  has 


SURGERY  OF  THE  EXTREMITIES  837 

been  removed  the  surfaces  of  the  bone  may  be  swabbed  with  ninety-five 
per  cent,  carbolic  acid,  which  may  be  left  in  contact  for  from  two  to  five 
minutes,  and  then  the  cavity  should  be  thoroughly  washed  with  strong  alco- 
hol to  remove  the  superfluous  carbolic  acid. 

It  has  been  our  custom  to  apply  strong  compound  tincture  of  iodine  to 
these  surfaces  after  the  alcohol  has  been  sponged  away  and  then  close  the 
wound  with  sutures  and  apply  a  large  antiseptic  dressing,  and  to  support 
the  extremity  by  means  of  a  splint.  If,  however,  there  is  doubt  about  the 
complete  removal  of  all  the  infected  tissue,  it  is  much  wiser  to  tampon  the 
cavity  with  iodoform  gauze,  and,  if  found  aseptic  after  a  few  days,  to  close 
the  wound  by  secondary  sutures. 

In  cases  operated  repeatedly  without  permanent  success,  it  is  especially 
desirable  to  obliterate  the  medullary  canal  completely  in  order  to  leave  no 
space  to  become  the  seat  of  a  new  infection,  or  that  may  contain  a  focus  of 
old  infection.  This  can  be  best  accomplished  by  chiseling  away  the  entire 
portion  of  bone  forming  the  walls  of  the  medullary  canal,  except  on  one 
side.  It  is  not  necessary  to  retain  much  bone,  as  repair  will  begin  at  once, 
and  in  a  few  weeks  the  bone  will  again  have  its  normal  size.  It  is,  however, 
important  to  exercise  care  not  to  fracture  the  bone  during  the  operation. 
The  patient  should  be  kept  thoroughly  under  the  influence  of  the  anesthetic, 
as  a  sudden  motion  on  his  part  may  result  in  a  fracture. 

SEPTIC  INFECTION  OF  THE  EXTREMITIES. 
Typical  Case. 

The  patient  is  forty-eight  years  of  age,  works  in  a  lumber  yard,  and 
gives  the  following  history:  His  family  history  is  negative.  He  suffered 
from  the  ordinary  diseases  of  childhood;  four  years  ago  he  had  pneumonia, 
but  otherwise  has  always  been  well.  Four  clays  ago  he  noticed  a  slight 
swelling  of  his  left  thumb,  which  was  ascribed  to  the  fact  that  two  weeks 
ago  a  small  sliver  of  wood  entered  at  the  point  of  the  swelling.  At  first  he 
paid  no  attention  to  this,  but  last  night  he  suddenly  began  to  feel  exceedingly 
ill.  The  swelling  extended  rapidly  over  the  entire  hand,  and  red  lines  indi- 
cate the  course  of  the  superficial  lymph  channels  along  the  palmar  surface 
of  the  arm  to  the  axilla.  There  is  a  very  small  point  at  which  the  sliver 
entered  the  end  of  the  thumb.  All  the  infected  portions  are  exceedingly 
tender. 

The  patient  is  a  strong,  well  nourished  man.  A  physical  examination 
shows  his  heart,  lungs,  kidneys  and  abdominal  organs  to  be  normal.  His 
temperature  at  the  present  time  is  iO2l/2Z  F.,  pulse  124,  respiration  20.  He 
has  the  appearance  of  being  extremely  ill.  During  the  past  night  he  was  de- 
lirious, and  his  friends  state  that  his  fever  was  very  high — although  the 
temperature  was  not  measured. 

If  this  patient  were  permitted  to  sit  up  or  walk  about  with  some  small 
local  dressing  applied  to  his  thumb,  we  are  certain  that  in  a  few  days  he 
would  develop  a  palmar  abscess,  and  judging  from  the  extension  of  the 
swelling  at  the  present  time,  this  would  later  be  followed  by  an  abscess  of 
the  forearm,  and  still  later  the  axillary  glands  would  suppurate. 

Every  practical  surgeon  has  made  the  following  observation  in  these 
patients  many  times,  and  possibly  also  upon  himself.  A  slight  infection  of 
the  finger  occurs  from  a  prick  with  a  needle  or  from  some  other  slight  in- 
jury. During  the  clay  the  finger,  and  even  the  hand,  becomes  painful.  The 


838  SURGERY    OF    THE    EXTREMITIES 

next  morning  the  pain  has  entirely  disappeared  and  the  patient  imagines 
himself  well,  but  during  the  day  the  pain  returns,  perhaps  a  little  more  se- 
vere than  the  day  before,  and  on  the  following  night  it  again  disappears, 
only  to  a  less  extent.  After  a  few  further  repetitions  a  serious  infection 
may  become  established,  resulting  in  the  destruction  of  a  considerable 
amount  of  tissue,  which  will  probably  be  followed  by  a  marked  impairment 
of  the  function  of  the  extremity. 

The  explanation  is  very  simple.  During  the  day  when  the  extremity  is 
frequently  moved  the  infectious  material  is  carried  from  its  circumscribed 
area  to  points  farther  up  the  arm.  The  following  night  this  progress  is 
again  inhibited,  because  of  the  complete  rest  in  the  muscles  of  the  arm,  and 
there  is  a  corresponding  diminution  in  the  symptoms.  If  the  rest  be  con- 
tinued the  progress  is  permanently  inhibited  and  the  patient  recovers  com- 
pletely. If  this  is  not  done  it  will  ordinarily  advance  until  he  is  so  ill  that 
rest  is  compulsory. 

Treatment. 

Our  treatment  consists  in  carefully  cutting  away  the  thickened  skin  over 
the  point  of  the  thumb  in  order  to  permit  any  infectious  material  still  ex- 
isting at  the  original  point  of  entrance  to  escape.  The  great  danger  to  the 
patient,  however,  comes  from  the  infection  which  has  already  extended  be- 
yond the  original  area,  and  we  consequently  apply  to  the  entire  arm  the 
dressing  shown  herewith.  The  patient  will  also  receive  a  cathartic,  prefer- 
ably two  ounces  of  castor  oil  in  the  foam  of  beer  or  malt  extract,  in  order 
to  remove  from  his  alimentary  canal  any  products  of  decomposition  which 
might  depress  his  general  system.  As  a  result  of  this  dressing,  combined 
with  absolute  rest,  we  will  expect  the  temperature  to  be  practically  normal 
within  two  days,  and  the  worst  consequence  that  can  happen  lies  in  a  cir- 
cumscribed, harmless  abscess  that  will  heal  within  a  few  days  after  being 
laid  open. 

Even  the  severest  infections  of  the  extremities,  such  as  may  result  from 
wounds  received  at  post  mortems,  pin  pricks  or  slight  abrasions,  nail  punc- 
tures, etc.,  will  subside  within  a  few  days  if  the  two  very  simple  require- 
ments indicated  above  are  established.  The  more  important  of  these  is  rest, 
The  septic  material  is  carried  from  the  original  point  of  infection  through 
the  lymph  channels.  It  is,  however,  a  fact  which  has  been  repeatedly  dem- 
onstrated, that  this  progress  is  very  slow  if  the  extremity  remains  perfectly 
at  rest,  and  much  more  rapid  if  the  muscles  of  the  arm  are  active,  because 
their  contractions  virtually  pump  the  micro-organisms  onward  in  the  lymph 
channels.  If  a  patient  suffering  from  an  infection  of  the  hand  or  finger  is 
placed  completely  at  rest  the  inflammation  will  remain  nearly  stationary, 
even  if  there  be  no  further  treatment,  while  as  soon  as  the  patient  begins  to 
use  the  extremity  there  is  a  marked  exacerbation  of  the  inflammation.  This 
we  have  observed  a  great  many  times. 

Antiseptic  Dressings. 

The  next  important  point  in  the  treatment  consists  in  the  application 
of  large,  moist,  antiseptic  dressings.  It  does  not  matter  whether  the  infec- 
tion be  slight  or  severe  at  first,  one  cannot  feel  certain  that  it  will  not  in- 
crease in  severity,  and  this  increase  in  severity  may  be  followed  by  very 
unfortunate  results — such  as  palmar  abscesses,  necrosis  of  the  tendon 
sheaths  with  the  subsequent  deformity  and  stiffness,  or  the  axillary  glands 
may  become  involved  and  be  destroyed  by  suppuration,  which  may  be  fol- 


PLATE  CLIV. 

LARGE,  MOIST  ANTISEPHC  DRESSING. 

Each  finger  is  first  separately  covered  with  gauze.  Then  the  entire  hand  and 
arm  to  the  shoulder  are  wound  loosely  with  gauze,  then  with  cotton,  all  being  saturate  i 
with  a  mild  antisentic  solution.  The  entire  dressing  is  tiiLii  covered  with  rubber  c.otli 
or  some  other  impervious  material.  The  patient  should  be  in  the  recumbent  position 
and  the  extremity  elevated.  The  object  of  the  picture  is  to  show  the  extent  and 
size  of  the  dressing. 


SURGERY    OF    THE    EXTREMITIES  84! 

lowed  by  pyemia  and  death.  This,  however,  will  not  be  the  case  if  the  ex- 
tremity is  put  absolutely  at  rest  as  soon  as  the  diagnosis  is  made  and  a  large, 
moist,  antiseptic  dressing  is  applied.  Plate  CLIV  illustrates  this  dressing 
It  consists  of  five  to  ten  yards  of  soft,  antiseptic  gauze,  loosely  rolled  around 
each  finger  separately,  then  about  the  hand,  wrist,  forearm  and  arm  to  the 
shoulder.  This  is  surrounded  by  a  pound  of  absorbent  cotton,  and  then  by  a 
rubber  cloth,  to  confine  the  moisture  and  retain  the  temperature.  Fresh  an- 
tiseptic solution  is  poured  into  the  dressing  every  one  to  six  hours  so  as  to 
keep  the  extremity  constantly  in  contact  with  this  fluid. 

The  dressing  is  renewed  once  in  forty-eight  hours  and  the  entire  ex- 
tremity carefully  inspected  to  locate  circumscribed  abscesses  which  may 
form,  although  the  vast  majority  of  these  cases  get  perfectly  well  without 
the  development  of  an  abscess.  Occasionally  the  circumstances  may  be  such 
as  to  make  it  desirable  to  inspect  the  extremity  after  twenty-four  hours,  but 
usually  it  is  better  to  leave  the  dressing  undisturbed  for  a' longer  period.  If 
an  abscess  has  formed  this  is  laid  open,  care  being  taken  not  to  open  into 
any  of  the  surrounding  healthy  tissue,  for  that  is  likely  to  result  in  a  pro- 
gressive infection.  Above  all  things  these  extremities  should  not  be 
squeezed  or  manipulated  during  the  dressing.  We  have  frequently  seen  a 
patient's  temperature  rise  several  degrees,  and  the  infection  progress  to  a 
marked  extent,  after  such  manipulations.  It  is  painful  to  observe  a  surgeon 
inflicting  upon  one  of  these  patients  what  might  be  termed  diagnostic  mas- 
sage, and  forcing  the  septic  material  out  of  its  fairly  circumscribed  and  con- 
sequently relatively  harmless  position  into  the  surrounding  tissues. 

Avoid  Manipulations. 

The  slightest  touch  will  suffice  to  indicate  the  presence  of  a  circum- 
scribed accumulation  of  pus,  and  still  one  frequently  observes  a  physician 
squeezing  and  crushing  these  inflamed  tissues  for  several  minutes,  to  no 
purpose  whatever  apparently,  while  he  is  collecting  his  sluggish  thoughts. 
It  is  well  to  remember  that  much  harm  may  be  done  in  this  manner. 

If  there  is  a  deep-seated  abscess  on  the  palmar  side  of  the  hand  it  may 
easily  be  located  by  gently  pressing.  There  is,  however,  no  doubt  but  that 
it  is  much  better  for  the  patient  if  these  abscesses  are  opened  a  little  too  late 
than  a  little  too  early,  as  their  contents  become  much  less  virulent  from  day 
to  day  and  if  the  extremity  is  kept  at  rest  there  will  be  no  progressive  in- 
fection. 

We  have  recently  looked  up  the  cases  of  severe  infection  of  the  fingers 
which  we  have  treated  in  one  hospital  during  the  past  two  years,  and  find 
that  there  were  forty-six  during  that  time,  and  of  this  entire  number  there 
was  not  one  coming  without  an  incision  of  the  palm  or  forearm  whose  hand 
was  disabled  as  a  result  of  the  infection  or  the  treatment ;  while  among 
those  who  had  been  treated  with  small  dressings  of  any  kind,  without  abso- 
lute rest  and  with  the  palms  or  forearms  incised  before  entering  the  hos- 
pital, deformed  and  stiff  hands  were  the  rule. 

We  have  made  extensive  observations  with  a  large  number  of  these 
cases  and  have  found  that  the  patients  have  progressed  most  favorably  when 
the  following  antiseptic  solution  was  poured  into  the  dressing  every  one 
to  six  hours : 

Boric  acid,  saturated  solution  in  water six  parts. 

Carbolic   acid,   five   per   cent,    solution one  part. 

Alcohol,  ninety-five  per  cent one  part. 


842  SURGERY    OF    THE    EXTREMITIES 

It  is  astonishing  how  rapidly  a  most  violent,  progressing  infection  of 
the  extremity  will  be  changed  into  a  perfectly  stationary,  harmless  affection 
if  the  two  conditions  mentioned  are  thoroughly  applied. 

Typical  Case. 

A  young,  vigorous  farmer,  about  thirty  hours  before  entering  the  hos- 
pital, had  produced  a  slight  injury  with  a  dirty  file  while  repairing  some 
portion  of  an  old  halter.  During  this  short  time  the  infection  had  made 
such  violent  progress  that  the  patient  seemed  to  be  in  a  hopeless  state.  He 
was  delirious,  his  entire  arm  to  the  shoulder  was  edematous  and  red,  his 
hand  was  severely  swollen,  the  fingers  were  gangrenous  and  this  condition 
had  progressed  upwards  rapidly.  Under  the  treatment  just  described,  the 
line  of  demarcation  formed,  there  was  no  further  progress  in  the  infection 
and  the  edema  subsided  rapidly.  Before  entering  the  hospital  a  small  dress- 
ing had  been  applied.  Until  the  patient  became  delirious  he  was  permitted 
to  walk  about  the  room,  which  he  did  in  the  hope  of  reducing  his  suffering. 
As  usual,  the  pain  subsided  rapidly  after  the  form  of  treatment  before  men- 
tioned was  employed,  and  there  was  no  progress  of  the  disease,  although  this 
had  been  constant  and  very  rapid  previously.  We  have  chosen  this  case  for 
illustration  because  of  its  great  violence. 

It  is  doubtful  whether  the  antiseptic  solution  in  the  dressing  has  much 
influence  upon  the  infection  directly,  or  whether  the  benefit  comes  entirely 
from  the  effect  of  the  rest  and  the  moist  heat.  Professor  Kahlenberg  has 
demonstrated  positively,  that  within  a  few  minutes  after  the  application  of 
moist  boric  acid  dressings  to  the  skin  the  urine  shows  the  presence  of  the 
antiseptic,  consequently  it  seems  reasonable  to  suppose  that  there  is  direct 
benefit  from  the  use  of  this  remedy. 

CARBUNCLE. 

At  this  point  it  seems  proper  to  discuss  another  localized  infection  so 
characteristic  in  its  appearance  as  to  be  classified  separately.  A  circum- 
scribed area  of  the  skin,  most  commonly  upon  the  posterior  surface  of  the 
neck,  or  upon  the  back,  becomes  indurated,  then  red  and  later  purple  in 
appearance,  then  a  number  of  small  perforations  occur  upon  its  surface  from 
which  a  few  drops  of  pus  are  discharged.  The  induration  is  usually  one  to 
five  cm.  in  diameter,  but  it  may  extend  from  this  focus  until  a  large  area 
has  been  included.  The  progress  is  through  the  subcutaneous  fat.  It  may 
be  uniform  in  every  direction  or  extend  irregularly,  a  larger  and  larger 
portion  of  the  skin  surrounding  the  original  center  attaining  a  honeycombed 
appearance.  The  infected  area  is  exceedingly  painful  and  the  patient  has 
the  general  appearance  of  one  who  is  severely  ill.  If  the  disease  has  ex- 
isted for  a  considerable  period  the  center  of  the  area  will  contain  a  cir- 
cumscribed slough  of  connective  tissue  saturated  with  pus  opposite  each  one 
of  the  small  perforations  in  the  skin.  Unless  vigorous  treatment  is  insti- 
tuted the  disease  usually  progresses  quite  rapidly  and  its  progress  is  especial- 
ly favored  by  motion  in  the  part  or  by  manipulation,  which  seem  to  force 
the  infectious  material  into  the  surrounding  subcutaneous  connective  tissue. 
Often  resistarce  has  been  greatly  reduced  by  the  presence  of  diabetes.  In- 
deed in  many  of  these  cases  a  carbuncle  occurs  only  because  of  the  dia- 
betes, and  were  it  not  for  this  condition  the  infection  which  has  resulted  in 
a  carbuncle  would  have  caused  but  a  very  slight  circumscribed  superficial 


SURGERY  OF  THE  EXTREMITIES  843 

infection  which  would  have  disappeared  spontaneously  very  quickly,  had 
not  the  tissues  furnished  such  an  excellent  culture  medium  for  the  micro- 
organisms. In  every  instance  it  is  important,  therefore,  to  examine  the 
urine  in  order  to  determine  whether  or  not  the  patient  has  diabetes. 

Operative  Technique. 

Whenever  it  can  be  done  the  most  satisfactory  form  of  treatment  con- 
sists in  making  a  crucial  incision  down  to  the  base  of  the  infected  tissue, 
dissecting  back  the  four  flaps  of  skin  thus  formed  and  then  removing  all  of 
the  infected  parts.  The  cavity  thus  formed  is  then  carefully  sponged  with 
ninety-five  per  cent,  carbolic  acid  and,  after  a  minute,  is  tamponed  with 
gauze  saturated  with  strong  alcohol.  This  dressing  is  renewed  daily  until 
the  wound  is  perfectly  clean,  when  the  edges  of  the  flaps  are  drawn  toward 
each  other  and  the  space  permitted  to  heal  by  granulation,  or  if  the  defect 
is  too  large  it  may  be  covered  with  Thiersch  skin  grafts. 

If  this  radical  operation  cannot  be  performed  in  any  given  case  one 
may  usually  secure  a  satisfactory  result  by  employing  the  following  method : 
From  five  to  ten  drops  of  a  fifty  per  cent,  solution  of  ninety-five  per  cent, 
carbolic  acid  in  glycerine  is  injected  into  the  base  of  the  indurated  area,  at 
points  two  cm.  apart,  around  the  entire  circumference  of  the  carbuncle.  In 
this  manner  an  entire  circle  is  made  around  the  diseased  area.  It  is  best  to 
use  a  hypodermic  needle  and  inject  from  five  to  ten  drops  at  each  point  of 
puncture.  The  fluid  will  cause  the  albumen  in  the  pus  to  coagulate  and 
ooze  out  of  the  perforations  in  the  skin  over  the  center  of  the  carbuncle  in 
the  form  of  a  white  fluid.  This  should  be  sponged  away  with  pledgets  of 
cotton  saturated  with  alcohol  so  as  to  prevent  cauterization  of  the  sur- 
rounding skin  with  the  superfluous  carbolic  acid.  In  order  to  protect  the 
skin  against  this  accident  it  is  well  to  cover  it  thoroughly  with  vaseline  be- 
fore beginning  the  injections.  After  the  circle  has  been  completed,  the  sur- 
face is  covered  with  a  thick  layer  of  gauze  thoroughly  saturated  wTith  strong 
alcohol,  to  dilute  any  carbolic  acid  which  may  be  discharged  later.  The  pa- 
tient is  kept  at  rest  and  the  carbolic  acid  injections  may  be  repeated  once  or 
twice  if  necessary,  but  usually  one  treatment  will  suffice  or,  if  it  fails,  the 
radical  excision  of  the  infected  tissue  should  be  employed.  If  there  is 
marked  improvement  the  wound  is  dressed  with  moist  antiseptic  dressings 
daily  until  healed. 

If  diabetes  is  present  large  quantities  of  distilled  water  should  be  given 
in  order  to  eliminate  the  sugar  as  rapidly  as  possible,  and  the  diet  should  be 
carefully  regulated.  It  is  important  to  give  these  patients  an  abundance  of 
proper  food  and  prevent  the  absorption  of  products  of  decomposition  from 
the  alimentary  canal.  Castor  oil  and  mild  saline  laxatives  are  well  borne. 

VARICOSE  VEINS  OF  THE  LOWER  EXTREMITIES. 

Varicose  veins  in  the  lower  extremities  are  accompanied  by  a  great 
amount  of  pain  to  the  patient,  and  will  usually  result,  sooner  or  later,  in  the 
formation  of  an  ulcer  of  the  leg.  because  of  the  lack  of  nutrition  in  the  cir- 
cumscribed areas  drained  by  the  lower  end  of  the  saphenous  veins.  If  both 
the  superficial  and  the  deep  veins  are  varicose,  there  will  be  marked  edema 
of  the  entire  lower  extremity,  and  no  operative  treatment  is  of  any  avail. 
These  patients  will  progress  most  comfortably  if  the  bed  is  arranged  so  that 
the  lower  extremities  rest  upon  an  inclined  plane  regularly  at  night.  This 


844  SURGERY    OF    THE    EXTREMITIES 

relieves  the  impaired  veins  of  much  of  their  burden  and  they  have  an  op- 
portunity to  recuperate  slightly  each  night.  In  the  morning,  before  the  ex- 
tremities are  lowered,  well  fitting  elastic  stockings  should  be  applied,  to 
support  the  veins.  It  is  important  that  the  extremities  be  carefully  meas- 
ured so  that  the  stockings  may  fit  accurately,  and  that  the  measurement  is 
taken  after  the  patient  has  rested  in  bed  for  a  number  of  days  with  the 
legs  elevated,  so  that  all  of  the  edema  may  have  disappeared.  If  there  is  only 
circumscribed  or  superficial  edema,  the  condition  usually  depends  upon  the 
incapacity  of  the  valves  in  the  superficial  veins,  namely,  the  external  or  in- 
ternal saphenous,  or  both.  In  this  event,  the  patient  can  usually  obtain  per- 
manent and  perfect  relief  if  these  veins  are  excised,  especially  if  in  addition 
to  such  excision  all  the  superficial  veins  are  severed  transversely.  This  may 
be  accomplished  by  making  a  circular  incision  through  all  of  the  tissues  down 
to  the  deep  fascia  and  then  uniting  the  wound  in  the  skin  by  means  of  su- 
tures throughout.  It  is  still  better  if  the  incision  is  carried  through  the 
skin  and  superficial  fascia  and  the  veins  down  to  the  deep  fascia  about  the 
middle  of  the  leg,  through  the  circumference,  with  the  exception  of  an  inch 
opposite  the  spine  of  the  tibia,  and  the  same  distance  on  the  posterior  sur- 
face of  the  leg.  The  superficial  fascia  and  veins  between  the  skin  and  the 
deep  fascia  at  these  points  may  be  severed  by  passing  a  knife  under  the  skin 
with  the  cutting  edge  downward.  This  will  prevent  a  circular  scar  extend- 
ing entirely  around  the  leg.  A  further  improvement  in  this  operation  con- 
sists in  making  the  incision  obliquely  instead  of  exactly  at  right  angles  with 
the  leg.  The  operation  is  performed  with  a  constrictor  applied  to  the  thigh, 
so  there  can  be  no  hemorrhage  during  the  operation,  and  it  will  not  be 
necessary  to  ligate  any  of  the  veins,  the  constrictor  not  being  removed  until 
the  dressing  has  been  applied  and  the  patient  placed  in  bed,  writh  the  ex- 
tremity elevated. 

EXCISION  OF  THE  SAPHENOUS  VEINS. 

The  internal  saphenous  vein  is  more  commonly  affected  than  the  ex- 
ternal. To  determine  the  extent  of  the  excision  the  patient  should  be  per- 
mitted to  stand  erect  for  a  few  minutes  and  the  point  noted  to  which  the 
vein  is  enlarged.  It  should  then  be  excised  to  a  distance  several  inches 
above  this  point. 

Technique. 

The  extremity  is  elevated  and  held  for  several  minutes  until  the  veins 
have  become  entirely  empty.  Then  an  Esmarch  constrictor  is  applied  to  the 
thigh  high  up  and  the  vein  laid  bare  by  an  incision  extending  over  the  entire 
distance  through  which  it  is  enlarged.  The  uppermost  end  is  then  dissected 
free,  grasped  with  two  pairs  of  hemostatic  forceps  and  cut  between,  and  the 
upper  end  ligated.  The  vein  is  then  dissected  out  downward  throughout  the 
desired  length ;  the  larger  communicating  branches  being  caught  with  for- 
ceps and  ligated,  or  they  may  be  left  open  with  safety.  After  the  entire  vein 
has  been  excised  the  wound  is  closed  and  a  large  antiseptic  dressing  applied, 
so  that  the  pressure  upon  the  wound  will  be  uniform  and  mild.  The  con- 
strictor is  not  removed  until  the  patient  has  been  placed  in  bed  with  the  ex- 
tremity elevated.  The  extremity  should  be  left  in  an  elevated  position  for 
at  least  one  week  after  the  operation,  and  then  it  should  be  slowly  lowered. 
At  the  end  of  the  second  week  a  soft  flannel  bandage  may  be  applied  and  the 
patient  permitted  to  be  about.  It  is  well  for  the  patient  to  wear  a  flannel 


SURGERY    OF    THE    EXTREMITIES  845 

bandage,  applied  every  morning  before  the  foot  is  lowered,  for  a  number 
of  months.  It  is  also  wise  for  him  to  sleep  with  the  extremity  elevated  upon 
an  inclined  plane  so  as  to  relieve  the  deep  veins  during  the  night. 

Unnas'  Paste   Cast. 

In  mild  cases  of  varicose  veins  of  the  extremities  the  following  treat- 
ment, if  applied  for  a  period  of  from  three  months  to  one  year,  will  almost 
always  give  great  relief,  and  it  will  frequently  strengthen  the  veins  to  such 
an  extent  that  the  patient  may  remain  entirely  well  for  years. 

The  limb  should  first  be  kept  in  an  elevated  position  for  several  days 
and  nights  in  order  to  empty  the  veins  thoroughly  and  remove  any  edema 
that  may  be  present.  The  following  mixture  is  then  prepared.  Place  four 
parts  by  weight  of  plate  gelatin  in  ten  parts  of  distilled  water,  permit  this  to 
stand  over  night,  then  place  in  a  water  bath,  heat  in  this  way,  stir  constantly 
until  dissolved  ;  add  ten  parts  of  glycerine  w-hile  hot,  then  add  four  parts  of 
impalpable  oxide  of  zinc  powder.  Stir  constantly. 

Apply  ten  thicknesses  of  gauze  about  the  foot,  covering  the  toes  to  pro- 
tect them  against  contact  with  the  cast.  Apply  a  similar  amount  of  gauze 
around  the  upper  end  of  the  proposed  cast. 

If  this  precaution  is  not  taken  the  skin  will  be  severely  irritated  at  the 
upper  and  lower  ends  of  the  cast.  It  is  consequently  also  important  not  to 
apply  any  of  the  paste  beyond  the  margin  of  these  protecting  gauze  bands. 
The  surface  of  the  foot  and  leg  between  these  two  bands  is  now  thickly 
painted  with  the  hot  paste  by  means  of  an  ordinary  large  painter's  brush. 
The  surface  is  then  covered  with  a  thin  gauze  roller  bandage  two  inches 
wide,  great  care  being  taken  to  apply  the  bandage  smoothly.  These  band- 
ages are  now  continuously  covered  with  the  hot  paste  until  the  leg  has  been 
covered  with  about  four  layers  of  the  saturated  gauze  roller  bandages.  The 
cast  remains  elastic  after  it  is  dry.  It  may  be  worn  from  one  to  four  months, 
when  it  should  be  replaced. 

The  same  method  is  indicated  in  the  after-treatment  of  cases  that  have 
been  operated  for  the  relief  of  varicose  veins,  or  varicose  ulcer. 

VARICOSE   ULCERS. 

If  the  veins  have  been  varicose  for  quite  a  time,  especially  in  patients 
working  hard,  or  in  those  who  are  likely  to  subject  their  extremities  to 
traumatism.  an  ulcer  is  apt  to  form  on  the  lower  extremity.  So  long  as  the 
patient  remains  upon  his  feet,  and  so  long  as  nothing  is  done  to  relieve  the 
condition  in  the  veins,  such  an  ulcer  is  unlikely  to  improve.  If,  on  the  other 
hand,  the  patient  is  placed  in  bed  with  the  lower  extremities  elevated  upon  an 
inclined  plane,  the  pressure  removed  from  the  veins  and  consequently  the 
return  circulation  favored,  the  area  occupied  by  the  ulcer  becomes  better 
nourished  and  healing  is  promptly  favored.  The  same  is  true  after  ex- 
cision of  the  varicose  veins,  and  the  circular  incision  through  all  of  the  su- 
perficial veins,  provided  the  ulcer  has  not  existed  too  long  and  has  not  be- 
come of  such  size  that  its  covering  with  epithelium  is  impossible.  The  floor 
of  the  ulcer  will  then  become  composed  of  a  mass  of  hard,  connective  tissue, 
the  result  of  an  attempt  at  cicatrization  of  the  ulcer,  and  it  is  difficult  for 
epidermis  to  grow  over  this  surface. 

In  these  advanced  cases  it  is  better  to  excise  this  connective  tissue  and 
cover  the  entire  surface  with  Thiersch's  skin  grafts,  at  the  same  time  that 
operation  is  performed  for  the  relief  of  varicose  veins.  By  the  time  the 


846 

wound  of  the  latter  operation  is  healed  the  skin  grafts  will  have  firmly  ad- 
hered to  the  raw  surface  and  the  patient  at  once  relieved  of  the  ulcer. 

SKIN  GRAFTING. 

This  operation  is  indicated  wherever  a  surface  is  deprived  of  a  suffi- 
cient amount  of  skin  to  make  a  spontaneous  covering  impossible,  or  in 
cases  in  which  it  would  require  too  great  a  period  of  time,  or  in  which  the 
skin  formed  in  this  manner  would  not  be  sufficiently  substantial.  It  is  also 
indicated  after  the  removal  of  tumors  in  which  so  much  of  the  overlying 
skin  has  to  be  removed  as  to  make  it  impossible  to  bring  the  edges  properly 
together.  In  these  instances  the  operation  of  skin-grafting  may  be  carried 
out  at  once,  provided  the  hemorrhage  be  sufficiently  stopped  at  the  time  of 
the  operation.  The  same  is  true  after  the  excision  of  troublesome  scars 
after  burns  or  injuries. 

Technique. 

The  success  of  the  operation  depends  upon, 

1.  Absolutely  aseptic  conditions. 

2.  Securing  a  bloodless  surface  on  which  to  graft  the  skin. 

3.  The  accurate  application  of  the  skin  grafts ;  and 

4.  The  fact  that  the  grafts  have  not  been  injured  by  contact  with  any 
antiseptic  solution  between  the  time  of  their  removal  from  the  normal  skin 
and  that  of  their  application  to  the  raw  surface. 

The  area  from  \vhich  the  skin  is  to  be  removed  should  be  prepared 
as  carefully  as  though  any  other  operation  were  to  be  done.  The  most  con- 
venient place  from  which  to  obtain  skin  is  the  outer  surface  of  the  thigh. 
The  skin  is  removed  by  means  of  a  sharp  razor,  preferably  with  a  wide 
blade,  held  parallel  with  the  surface  of  the  extremity,  being  permitted  to 
slide  upon  the  thigh.  The  thickness  of  skin  to  be  removed  is  regulated 
carefully  by  the  method  of  holding  the  razor.  The  skin  should  be  stretched 
so  as  to  make  it  as  tense  as  possible.  Then  a  layer  should  be  shaved  off  by 
means  of  a  sawing  motion.  This  layer  should  contain  the  epidermis  and  a 
thin  portion  containing  the  tops  of  the  papillse. 

The  portion  cut  is  permitted  to  fold  itself  upon  the  surface  of  the  razor 
until  a  sufficiently  long  strip  has  been  removed  to  extend  across  the  ulcer  to 
be  covered.  This  may  be  calculated  very  easily,  so  that  each  successive  strip 
will  extend  quite  across  the  ulcer.  Neither  the  skin  nor  razor,  nor  the  sur- 
face to  be  grafted  upon,  should  be  wet.  If  this  precaution  is  taken  union  be- 
tween the  surfaces  will  take  place  almost  instantly. 

The  plan  practised  so  long  of  covering  the  razor,  the  skin  and  the 
portion  to  be  grafted  with  normal  salt  solution  reduces  the  chances  of  rapid 
and  perfect  union. 

In  order  to  spread  the  graft  over  the  area  to  be  covered  most  con- 
veniently the  sharp  edge  of  the  razor  should  be  placed  in  contact  with  this 
surface,  and  while  the  graft  is  being  pulled  off  this  edge  by  means  of  a 
needle  fastened  in  a  pair  of  hemostatic  forceps  the  razor  is  slowly  moved 
across  the  surface.  In  such  manner  the  graft  will  be  almost  perfectly  spread 
without  any  further  manipulation.  The  edges  may  he  still  further  adjusted 
by  means  of  a  pair  of  needles  fastened  in  hemostatic  forceps.  It  is  well  to  let 
the  delicate  edges  of  these  grafts  overlap  a  little.  After  the  entire  surface 
has  been  covered  with  a  series  of  these  sections  it  is  protected  by  the  applica- 


SURGERY  OF  THE  EXTREMITIES  847 

tion  of  a  network  of  rubber  adhesive  strips  from  two  to  three  millimeters  in 
width.  These  will  at  once  protect  the  underlying  skin  grafts  and  at  the  same 
time  make  it  possible  for  drainage  to  take  place  between  these  pieces.  A 
dressing  of  sterilized  gauze  is  placed  over  these  strips  and  held  in  position  by 
means  of  rubber  adhesive  straps.  A  thick  layer  of  absorbent  cotton  is  then 
put  over  all  and  held  in  position  by  means  of  a  soft  roller  bandage. 

After-treatment. 

The  wound  is  not  disturbed  for  one  week,  when  the  dressings  are  thor- 
oughly moistened  and  removed  without  disturbing  the  grafts.  It  is  im- 
portant that  the  dressings  be  not  pulled  upon  as  at  this  time  the  attachment 
between  the  grafts  and  the  raw  surface  is  still  very  slight.  If  the  dress- 
ing is  performed  carelessly  enough  harm  may  be  done  to  destroy  a  portion 
of  the  new  skin. 

After  the  dressing  has  been  removed,  together  with  the  rubber  protec- 
tive strips,  a  similar  toilet  to  the  one  first  applied  should  be  used  and  at  the 
end  of  a  second  week,  when  this  is  again  removed,  the  wound  is  usually 
found  perfectly  healed.  If  this  plan  is  carried  out  it  \vill  not  be  possible  to 
distinguish,  after  the  wound  has  healed,  the  different  grafts  applied;  the 
surface  being  perfectly  smooth,  there  will  be  no  traction  thereon,  and  it  will 
be  sufficiently  firm  to  bear  the  ordinary  abuses  to  which  the  skin  is  ex- 
posed. 

NERVE  SUTURES. 

Xerve  suturing  should  be  employed  where  a  nerve  is  severed  accident- 
ally during  an  operation,  where  a  portion  of  nerve  had  to  be  excised  to- 
gether with  some  malignant  growth,  where  a  portion  of  nerve  has  been  sev- 
ered or  destroyed  by  traumatism,  and  occasionally  in  cases  in  which  a  nerve 
has  been  caught  between  the  ends  of  a  fractured  bone  and  destroyed  by  the 
pressure  clue  to  the  formation  of  callus. 

If  the  nerve  be  sutured  immediately  after  being  severed  the  operation 
simply  consists  in  adjusting  the  nerve  ends  and  then  applying  a  sufficient 
number  of  fine  catgut  sutures  to  hold  them  in  perfect  coaptation.  It  does  not 
matter  whether  these  sutures  are  passed  through  the  trunk  of  the  nerve  or 
simply  include  the  sheath.  The  important  point  is  to  have  the  ends  of  the 
nerve  carefully  approximated.  It  is  well  to  adjust  over  the  line  of  suture 
in  the  nerve  a  convenient  piece  of  fascia,  which  can  be  obtained  in  the 
wound  by  means  of  a  few  fine  catgut  sutures. 

If  a  portion  of  nerve  has  been  destroyed  by  some  traumatism  the  dif- 
ficulty is  easily  managed,  as  one  of  the  principal  conditions  to  be  obtained 
in  order  to  secure  success  is  the  absence  of  tension  upon  the  nerve  ends.  In 
cases  in  which  the  ends  cannot  be  adjusted  absolutely  without  tension  the 
distance  between  them  should  be  bridged  over  in  the  following  manner : 

Technique. 

The  nerve  ends  are  cut  off  squarely  :  then  a  very  fine  cat-gut  suture  is 
passed  back  and  forth  between  the  divided  extremities,  each  time  passing 
through  the  end  at  a  little  distance  from  the  previous  point  of  perforation 
until  a  bundle  of  catgut  has  been  produced  approximately  the  size  of  the 
nerve  being  sutured.  This  should  be  applied  so  that  there  is  absolutely  no 
tension  upon  the  sutures,  which  should  lie  loose  between  the  two  nerve  ends. 
When  a  sufficient  amount  of  this  catgut  has  been  thus  arranged  the  ends 


SURGERY    OF    THE    EXTREMITIES 

are  tied  and  the  entire  bundle  of  catgut,  together  with  the  two  nerve  ends, 
is  covered  by  reflecting  a  flap  of  'fascia  over  them  and  attaching  them  to 
some  of  the  soft  tissues  beyond  by  means  of  a  few  fine  catgut  sutures.  By 
this  method  we  have  secured  perfect  functional  results  where  as  much  as 
three  inches  of  the  ulnar  nerve  had  been  destroyed  by  a  gunshot  wound,  and 
in  a  number  of  other  cases  we  have  had  equally  satisfactory  results  with 
this  form  of  grafting  nerves  by  means  of  intervening  catgut  sutures.  If 
the  nerve  has  been  severed  for  a  period  of  time  the  conditions  are  still 
further  complicated  because  the  ends  of  the  nerves  are  now  covered  with 
connective  tissue,  and  in  order  to  secure  satisfactory  functional  results  it  will 
be  necessary  to  absolutely  remove  all  of  this  connective  tissue.  The  tendency 
in  these  operations  is  always  to  cut  away  too  little  of  such  tissue  in  order  not 
to  increase  the  distance  between  the  ends  too  greatly.  Many  failures  are 
undoubtedly  due  to  this  disposition. 

With  section  through  a  relatively  healthy  nerve  and  a  distance  of  an 
inch  or  more  between  the  ends  the  chances  for  a  satisfactory  functional  re- 
sult are  much  greater  than  with  the  ends  directly  sutured  together,  and 
wherein  all  of  the  connective  tissue  which  has  resulted  from  the  healing  of 
the  nerve  stump  has  not  been  removed. 

We  would,  therefore,  emphasize  the  importance  of  cutting  away  a  suf- 
ficient amount  in  cases  in  which  nerve  grafting  is  practised  a  considerable 
time  after  the  nerve  has  been  severed.  Here  again  it  is  important  to  bear  in 
mind  that  a  condition  of  tension  is  the  worst  possible  one  to  be  obtained  in 
nerve  suturing. 

The  surgeon  will  often  encounter  no  small  amount  of  difficulty  in  find- 
ing the  nerve  ends  directly,  if  the  operation  is  performed  some  time  after 
the  injury  has  occurred,  for  the  traumatism  itself  and  the  subsequent  heal- 
ing has  usually  disturbed  the  relations  to  such  an  extent  that  the  nerve  can- 
not readily  be  discovered  by  searching  for  it  in  its  normal  anatomical  posi- 
tion. 

The  proximal  nerve  end  is  usually  considerably  enlarged  and  may  there- 
fore, be  found  more  easily,  as  it  can  be  felt  through  the  other  tissues.  This 
is  not  the  case  with  the  distal  nerve  end,  however,  which  is  rarely  enlarged 
at  all.  It  is  always  wise  in  these  cases,  if  the  nerve  end  is  not  found  at 
once,  to  locate  the  nerve  in  its  normal  position  at  some  distance  from  the 
point  of  injury  and  then  follow  it  down  to  where  it  has  been  severed.  It  is 
not  necessary  to  loosen  the  nerve  entirely  from  its  attachments  in  doing 
this.  All  that  needs  to  be  done  is  to  free  its  superficial  surface  and  follow 
this  down  to  the  end. 

If  the  nerve  has  been  included  in  callus,  resulting  in  a  paralysis  of  the 
portion  beyond  the  seat  of  the  fracture,  and  was  not  injured  directly  at  the 
time  of  the  fracture,  then  the  paralysis  will  have  come  on  slowly  and  not 
have  existed  directly  after  the  time  of  the  injury.  For  this  reason  it  is  im- 
portant to  obtain  a  perfect  history,  for  it  frequently  happens  that  a  nerve 
is  surrounded  by  callus,  and  as  this  increases  in  firmness  the  pressure  upon 
the  nerve  results  in  a  paralysis.  If  this  nerve  is  laid  bare  and  the  callus 
chiseled  away  the  nerve  may  be  released  from  its  grasp,  and  unless  it  has 
been  held  in  the  callus  for  a  lengthened  period  its  function  will  be  restored. 
In  order  to  prevent  from  again  becoming  compressed  in  the  callus  it  should 
be  carried  to  some  distance  from  the  original  point  of  incarceration  and  sur- 
rounded by  some  of  the  soft  tissues.  The  same  precaution  should  be  taken 
in  case  the  nerve  has  been  entirelv  severed  and  the  ends  caught  in  the  callus. 


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SURGERY    OF    THE    EXTREMITIES  851 

Too  much  stress  cannot  be  laid  upon  the  importance  of  carefully  observing 
cases  of  paralysis  following  fracture,  as  much  greater  success  follows  an 
early  than  a  late  operation. 

Prognosis. 

Where  the  nerve  is  sutured  directly  at  the  time  of  the  injury,  both  the 
immediate  and  the  remote  results  are  good.  Sensation  may  return  within  a 
few  hours  after  the  operation,  and  motion  will  begin  to  return  within  a  few 
weeks,  and  may  be  perfect  within  three  months.  If  the  operation  be  per- 
formed several  weeks  or  months  after  the  injury,  then  sensation  may  return 
within  a  short  time,  but  unless  the  action  of  the  muscles  is  maintained  by 
means  of  electricity  or  massage  atrophy  is  likely  to  occur  and  the  patient 
will  recover  but  slowly  from  the  paralysis  of  motion.  In  some  instances  the 
recovery  from  paralysis  of  motion  may  occur  as  late  as  one  or  two  years 
after  the  operation,  and  the  functional  result  may  continue  to  improve  for  a 
very  long  time  thereafter.  The  prognosis  is  relatively  much  better  the 
nearer  the  terminal  end  of  the  nerve  the  injury  occurs;  consequently  the 
suturing  of  one  of  the  large  nerves  does  not  give  nearly  so  good  a  prognosis 
as  the  smaller  ones.  During  the  past  few  years  considerable  progress  has 
been  made  in  transplanting  nerves,  or  portions  of  nerves,  to  supply  other 
nerves  which  have  lost  a  portion  of  their  substance  as  the  result  of  trauma- 
tism  or  operation.  This  plan  has  recently  been  extended  to  the  transplanting 
of  a  portion  of  a  normal  nerve  into  the  edge  of  a  nerve  which  has  become 
useless  as  the  result  of  central  disturbance,  such  as  poliomyelitis.  It  is 
claimed  that  in  this  manner  the  portion  of  the  nerve  which  remains  intact 
will  carry  on  the  function  of  the  entire  nerve,  while  the  portion  attached  to 
useless  nerve  will  in  time  restore  the  latter  to  a  fair  amount  of  activity. 

We  are  not,  as  yet,  prepared  to  judge  the  value  of  this  method. 

TENDON  SUTURES. 

If  a  tendon  is  severed  and  sutured  immediately  the  result  is  almost  in- 
variably satisfactory,  provided  the  wound  remains  aseptic.  It  does  not  mat- 
ter what  method  of  suturing  be  employed  so  long  as  the  tendon  ends  are  in 
apposition.  It  is,  however,  best  to  insert  the  sutures  in  such  a  manner  that 
they  cannot  readily  split  the  tendon  end  longitudinally.  This  is  best  ac- 
complished by  passing  the  suture  into  the  tendon  end,  then  out  through  one 
side,  then  passing  it  a  short  distance  across  the  tendon,  and  then  into  the 
tendon  again. 

If  a  considerable  portion  of  a  tendon  has  been  destroyed  the  ends  may 
be  united  in  the  manner  described  for  uniting  nerve  ends  at  a  distance.  The 
functional  results  in  these  cases  are  surprisingly  good.  We  have  repeatedly 
united  tendon  ends  more  than  six  inches  apart  with  perfect  functional  re- 
sults where  theoretically  one  could  expect  nothing  but  failure.  It  is,  how- 
ever, of  the  greatest  importance  to  avoid  tension. 

In  cases  in  which  a  tendon  is  contracted  it  may  be  lengthened  by  split- 
ting longitudinally  in  halves,  then  cutting  off  one  of  these  segments  in  one 
direction  at  the  end  of  this  longitudinal  incision  and  the  other  segment  in  the 
opposite  direction  at  the  other  end,  then  stretching  out  the  tendon  and 
uniting  the  two  segments  so  produced.  In  this  way  any  desired  amount, 
which  does  not  exceed  double  the  original  length,  may  be  very  easily  ob- 
tained. The  tendon  very  quickly  becomes  firm  and  the  functional  results 
are  highly  satisfactory. 


852  SURGERY  OF  THE  EXTREMITIES 

If  the  operation  is  performed  immediately  after  a  tendon  has  been 
severed  the  greatest  difficulty  is  encountered  in  finding  the  tendon  ends, 
which  usually  retract  a  greater  or  less  distance  within  their  sheaths.  If  a 
closed  pair  of  forceps  be  passed  up  through  the  sheath  until  it  reaches  the 
point  at  which  the  tendon  end  can  be  felt  and  then  opened,  this  end  can 
usually  be  caught  and  brought  down.  In  case  this  cannot  be  done  an  in- 
c.ision  may  be  made  opposite  the  point  to  which  the  tendon  has  retracted  and 
a  stitch  may  be  passed  through  the  tendon  end  and  threaded  in  the  eye  of 
an  old-fashioned  probe,  and  this  carried  through  the  sheath  of  the  tendon, 
and  then  by  drawing  on  the  suture  the  tendon  end  may  be  brought  down  and 
united  to  the  distal  end.  If  the  end  cannot  be  located  the  sheath  may  be 
split  until  it  is  reached.  It  is  then  brought  down  and  united  and  the  sheath 
sutured  over  it  with  fine  catgut  sutures.  Usually  this  does  not  result  in  any 
adhesions  between  the  sheath  and  the  tendon  unless  the  wound  becomes  in- 
fected. 

In  applying"  sutures  to  tendons  tension  should  be  avoided  and  the  su- 
tures should  never  be  tied  tightly  enough  to  cause  pressure  necrosis,  as  ten- 
don is  a  tissue  not  well  supplied  with  blood,  and  consequently  easily  injured 
in  this  manner. 

Healing  may  be  further  favored  in  applying  the  dressing  with  the  ex- 
tremity in  the  most  favorable  position  for  obtaining  a  relaxation  of  the  mus- 
cles belonging  to  the  tendons  which  have  been  sutured. 

TENDON  TRANSPLANTATION. 

In  patients  suffering  from  infantile  or  spastic  paralysis  it  is  often  possi- 
ble to  obtain  remarkably  satisfactory  functional  results  by  transplanting  the 
tendon  of  a  muscle  not  affected  by  the  paralysis  to  the  insertion  of  a  tendon 
of  a  muscle  which  is  affected.  This  may  be  best  illustrated  in  talipes  varus 
in  infantile  paralysis,  but  the  same  principle  applies  elsewhere. 

Here  the  equinus  position  may  be  overcome  by  lengthening  the  tendo 
achilles,  while  the  deformity  due  to  turning  in  of  the  foot  is  corrected  by 
transplanting  the  lower  attachment  of  the  tendon  of  the  tibialis  anticus 
muscle  from  the  inner  to  the  outer  side  of  the  foot.  An  incision  2  cm.  in 
length  is  made  just  below  the  anterior  annular  ligament  of  the  ankle,  direct- 
ly over  the  tendon  of  the  tibialis  anticus  muscle.  A  blunt  hook  is  passed 
around  this  for  the  purpose  of  making  traction.  Then  a  similar  incision  is 
made  over  the  attachment  of  the  tendon  to  the  inner  surface  of  the  cunei- 
form bone.  The  tendon  is  then  loosened  from  its  lower  attachment,  which 
may  be  facilitated  by  drawing  gently  upon  the  blunt  hook.  A  third  incision 
is  then  made  over  the  point  of  insertion  of  the  peroneus  brevis  to  the  outer 
surface  of  the  fifth  metatarsal  bone.  The  space  between  the  first  and  the 
third  incisions  is  then  tunneled  with  a  pair  of  blunt  forceps,  and  the  end  of 
the  tendon  drawn  through  this  channel  and  carefully  attached  to  the  tendon 
of  the  peroneus  longus  by  means  of  fine  chromicized  catgut  sutures  near  the 
]X)int  of  attachment  of  the  latter  muscle,  or  to  the  point  of  attachment  of  the 
peroneus  brevis.  The  three  wounds  are  then  sutured  and  the  foot  dressed 
in  a  plaster  of  Paris  cast  at  a  little  less  than  a  right  angle.  The  splint  is 
worn  for  three  months.  In  our  experience  this  operation  has  given  very  sat- 
isfactory results. 

It  is,  of  course,  important  that  the  muscle  to  which  tendon  is  to  be 
transplanted  be  in  a  fairly  normal  functional  condition. 

It  is  unnecessary  to  carry  the  application  of  this  principle  through  the 


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SURGERY    OF    THE    EXTREMITIES  855 

various  operations  in  which  it  may  be  employed  as  any  one  sufficiently  fa- 
miliar with  anatomy  may  select  from  the  muscles  those  best  suited  for  the 
purpose  of  substitution  for  those  which  are  completely  or  partly  paralyzed. 

TUBERCULOSIS  OF  THE  JOINTS. 

This  condition  is  characterized  by  its  slow  beginning,  by  its  usual  limi- 
tation to  one  joint,  by  the  tendency  to  fixation  of  the  joint,  and,  later,  by 
atrophy  of  the  muscles,  both  above  and  below  the  affected  part.  Its  location 
is  often  determined  by  a  traumatism,  although  this  cannot  always  be  estab- 
lished, and  where  there  is  a  history  of  injury  the  surgeon  cannot  always 
exclude  the  possibility  of  coincidence. 

Usually  it  is  secondary  to  tuberculosis  of  the  respiratory  or  alimentary 
tract,  the  tonsils  or  the  lymph  glands,  the  bacilli  having  been  carried  to  the 
vicinity  of  the  epiphyseal  line  of  the  bones  or  to  the  joint  surfaces  by  the 
blood-stream.  It  is  therefore  of  the  greatest  importance  that  the  surgeon's 
attention  be  primarily  directed  toward  the  improvement  of  the  patient's 
general  health,  which  can  be  best  accomplished  by  bettering  his  hygienic 
surroundings,  nutrition  and  habits  of  life ;  and  by  administering  tonics  and 
concentrated  foods  and  some  form  of  creosote.  Above  all  things  he  should 
not  be  permitted  to  continue  living  under  the  conditions  which  primarily 
gave  rise  to  his  disease.  These  points  are  of  great  importance,  not  only  in 
obtaining  a  recovery  from  the  immediate  disease,  but  also  for  the  purpose 
of  securing  permanency  of  cure.  It  is  virtually  always  necessary  to  change 
the  dwelling  of  these  patients,  if  not  the  climate ;  to  change  their  food,  regu- 
late their  hours  of  rest,  and  frequently  their  occupations.  This  having  been 
done,  the  treatment  of  the  joint  involved  will  depend  upon  its  location  and 
the  extent  to  which  the  disease  has  progressed ;  but  in  any  case  as  nearly 
complete  rest  as  possible  for  the  joint  is  most  to  be  desired,  especially  if  this 
can  be  obtained  without  confining  the  patient  to  bed.  If  the  disease  is  in  an 
incipient  stage,  rest  alone,  with  the  conditions  described  above,  will  usually 
suffice  to  produce  a  recovery. 

A  light  cast  made  of  plaster  of  Paris,  very  carefully  constructed,  and 
strengthened  by  the  incorporation  of  thin  strips  of  tough  wood,  such  as  are 
used  in  the  manufacture  of  market  baskets,  is  usually  the  most  desirable 
dressing,  unless  the  patient  can  afford  a  similar  dressing  manufactured  of 
aluminum.  The  cast  should  be  applied  over  some  elastic  woven  material,  ar- 
ranged in  a  double  layer,  so  that  any  friction  will  not  be  directly  against  the 
skin,  but  against  the  second  laver,  which  will  remain  free. 

If  the  ankle  or  the  knee  joint  is  involved,  it  is  best  to  draw  two  closely 
fitting:  stockings  over  the  extremity. 

The  cast  should  be  worn  for  a  number  of  months  after  the  joint  is 
apparently  perfectly  well. 

HIP  JOINT  TUBERCULOSIS. 

In  the  hip  joint  the  treatment  by  fixation  with  a  plaster  of  Paris  cast 
should  be  supplemented  by  weight-and-pnlley  extension,  to  be  applied  at 
night,  for  a  period  of  at  least  two  years  after  the  joint  has  apparently  fully 
recovered,  as  this  seems  to  prevent  recurrence,  deformity,  to  increase  the 
comfort  of  these  patients,  and  to  remind  them  of  the  necessity  of  avoiding 
traumatism  for  a  considerable  time.  The  extension  is  made  by  applying  a 
strip  of  rubber  adhesive  plaster  from  eight  to  twelve  centimeters  in  width. 


856  Sl'KGEKY    OF    THE    EXTREMITIES 

to  the  inner,  and  outer  surface  of  the  entire  thigh  and  leg,  and  holding  them 
in  place  by  a  roller  bandage.  These  plaster  strips  are  attached  to  the  cord 
which  passes  over  the  pulley  to  the  weight,  by  means  of  two  cords  at- 
tached to  a  cross-piece  of  wood  eight  to  fifteen  centimeters  in  length.  The 
lower  end  of  the  bed  should  be  elevated  from  ten  to  twenty  centimeters,  in 
order  to  secure  counter-extension  from  the  weight  of  the  body.  The  weight 
employed  should  be  from  one-tenth  to  one-fifth  of  the  weight  of  the  body, 
the  correct  amount  being  determined  by  the  comfort  of  the  patient.  It  is 
well  to  begin  with  a  light  weight  and  increase  gradually. 

If  rest  and  hygienic  measures  alone  are  not  sufficient  to  obtain  a  cure, 
which  may  usually  be  determined  by  an  increase  in  the  pain,  or  that  the 
swelling  does  not  subside,  or  that  a  point  of  fluctuation  appears  in  the  vicin- 
ity of  the  joint,  then  it  will  become  necessary  to  open  the  joint  and  remove 
the  diseased  tissues,  consisting  of  portions  of  the  capsule,  the  synovial  mem- 
brane and  cartilage  of  the  joint,  and  in  advanced  cases  usually  some  portion 
of  bone. 

Often  the  radical  operation  may  be  postponed  until  the  treatment  by 
means  of  injection  with  a  mixture  of  iodoform  and  glycerine  has  been  tried. 
This  will  be  described  presently. 

Technique. 

In  children,  the  least  possible  amount  of  tissue  should  be  removed,  as  in 
a  great  majority  of  cases  this  will  suffice  to  produce  a  cure  quite  as  fre- 
quently as  a  more  extensive  operation,  and  because  the  less  tissue  removed 
the  less  will  be  the  deformity,  and  likelihood  of  impairment  in  the  future 
growth  of  the  extremity. 

In  adults  conditions  are  somewhat  different.  Here  an  excision  of  a 
sufficient  amount  of  bone  to  insure  anchylosis  is  much  more  likely  to  cause 
a  satisfactory  outcome,  especially  in  the  hip  and  knee  joints,  both  as  regards 
permanency  of  cure  and  preservation  of  function. 

The  anchylosis  favors  strength  and  the  absence  of  motion  gives  free- 
dom from  pain.  The  permanency  of  cure  depends  to  no  small  degree  upon 
the  fact  that  any  slight  focus  of  infection  which  may  have  been  overlooked 
is  much  less  likely  to  be  kindled  into  activity  if  the  joint  is  placed  perfectly 
at  rest  by  the  anchylosis.  Moreover,  the  excision  of  a  sufficient  amount  of 
bone  to  secure  this  condition  increases  the  likelihood  of  a  complete  removal 
of  all  the  diseased  tissue.  After  the  diseased  tissue  has  been  completely 
removed,  the  raw  surfaces  should  all  be  thoroughly  and  repeatedly  swabbed 
with  a  ninety-five  per  cent,  solution  of  carbolic  acid  for  a  period  of  five 
minutes,  the  superfluous  acid  being  washed  away  with  strong  alcohol.  After 
this,  it  is  well  to  apply  strong-  compound  tincture  of  iodine  to  the  entire  sur- 
face, and  then  a  ten  per  cent,  solution  of  iodoform  and  glycerine,  after 
which  the  wound  is  to  be  closed  with  deep  sutures  of  catgut  and  superficial 
sutures  of  any  desired  material.  If  any  doubt  exists  as  to  the  aseptic  state  of 
the  joint  when  the  operation  has  been  completed,  it  should  be  freely  drained 
with  rubber  tubes  or  with  iodoform  gauze  passed  transversely  through  the 
articulation.  The  joint  is  then  covered  with  a  large  dressing  anrl  immo- 
bilized by  plaster  of  Paris  or  splints. 

All  the  joints  of  the  upper  and  lower  extremities,  with  the  exception  of 
the  shoulder  and  the  hip  joint,  are  operated  after  the  application  of  an  Es- 
march  constrictor.  This  facilitates  the  work  greatly  and  it  is  an  easy  mat- 
ter to  avoid  all  the  important  blood  vessels  during  the  operation,  hence  it  is 
not  necessary  to  remove  the  constrictor  before  suturing  the  wound  and  ap- 


PLATE  CLVIT. 

EXCISION  OF  ANKLE  \\ITH    IKANSVEKSE  ANTERIOR  INCISION 
Similar  forceps  being  placed  upon  sutures  inserted  in  the  two  free  ends  cr 
each  cut  tendon  for  identification. 


SURGERY  OF  THE  EXTREMITIES  859 

plying  the  dressing.  If,  however,  there  is  any  fear  in  the  mind  of  the  op- 
erator of  hemorrhage  later,  it  is  always  best  to  remove  the  constrictor  before 
suturing  the  wound,  carefully  grasp  all  bleeding  joints  with  artery  forceps 
and  ligate  them  before  closing  the  wound. 

RESECTION  OF  THE  ANKLE  JOINT. 

Nothing  has  been  said  concerning  the  operation  itself  in  connection 
with  each  joint,  because  the  typical  operations  outlined  in  every  text-book  are 
quite  as  satisfactory  as  any  we  may  describe,  with  the  exception  of  the 
method  for  resection  of  the  ankle  joint.  The  operation  which  is  here  out- 
lined is  not  generally  practised,  but.  any  surgeon  who  has  once  tried  this 
mode  will  always  continue  to  employ  it,  as  it  insures  a  most  satisfactory 
approach  to  the  diseased  tissues,  and  the  results  are  likewise  most  satisfac- 
tory, both  as  regards  the  functional  effects  and  permanency  of  cure.  This  is 
true  even  in  cases  that  seem  quite  hopeless  with  any  other  method. 

Technique. 

An  incision  is  carried  directly  across  the  anterior  surface  of  the  ankle 
from  malleolus  to  malleolus  through  the  skin,  superficial  and  deep  fascia  and 
the  sheaths  of  all  of  the  tendons  in  the  course  of  the  wound.  Externally  the 
peroneal  artery  and  nerve  should  be  avoided,  as  well  as  the  tendons  of  the 
peroneal  muscles,  which  may  readily  be  drawn  out  of  the  way.  Internally 
the  posterior  artery  and  nerve  should  be  protected.  Each  tendon  is  then 
lifted  up  in  the  incision  and  transfixed  with  two  fine  catgut  sutures  from 
one  to  two  centimeters  apart.  These  sutures  are  caught  in  similar  artery 
forceps  for  purposes  of  identification,  then  the  tendon  is  cut  transversely 
between  these  sutures.  After  all  the  tendons  have  been  disposed  of  in  like 
manner,  the  joint  is  opened  by  a  free  transverse  incision  and  the  sole  of  the 
foot  forced  back  upon  the  calf  of  the  leg.  In  this  manner  the  entire  joint  is 
opened  freely,  so  that  all  diseased  tissue  may  be  removed.  After  this  has 
been  accomplished,  as  described  in  connection  with  the  treatment  of  tuber- 
culous joints  in  general,  the  foot  is  placed  in  position,  the  tendons  carefully 
adjusted,  which  may  be  done  with  great  ease,  because  the  two  sutures  upon 
two  corresponding  tendon  ends  are  fastened  to  hemostatic  forceps  of  the 
same  pattern.  Each  tendon  is  carefully  sutured  and  a  fine  stitch  placed  in 
the  fascia  to  cover  the  line  of  suture  in  the  tendon.  Then  the  skin  is  su- 
tured over  all.  If  drainage  seems  necessary,  it  is  applied  through  and 
through,  and  even  in  cases  apparently  requiring  no  drainage,  we  have  usual- 
ly passed  a  few  strands  of  catgut  or  silkworm  gut  entirely  across  the  foot, 
permitting  the  ends  to  protrude  from  the  lower  angles  of  the  wound  so  as 
to  drain  the  serum  which  may  be  secreted  by  the  large  surface  during  the 
first  few  days.  A  large  dressing  is  applied  and  the  foot  immobilized  in  a 
position  at  a  little  less  than  a  right  angle. 

After-treatment. 

The  foot  is  elevated  in  order  to  favor  return  circulation.  If  drainage 
has  been  used,  this  is  left  in  place  from  one  to  two  weeks.  The  dressing  is 
not  changed,  unless  indicated  by  the  discharge,  for  a  week  or  ten  days,  in 
order  to  avoid  moving  the  foot,  and  after  that  as  seldom  as  possible  for 
the  same  reason. 
Prognosis. 

The  prognosis  is  very  good  after  this  operation.    The  free  exposure  of 


SURGERY    OF    THE    EXTREMITIES 

the  surfaces  insures  thoroughness,  and  consequently  the  cure  is  usually 
permanent.  The  anchylosis  of  the  surfaces  immediately  in  the  field  of  op- 
eration does  not  interfere  with  movement  because  the  tarso-metatarsal  joints 
will  supply  the  motion  necessary.  The  tendons  unite  readily  and  act  nor- 
mally. There  is  no  operation  for  the  relief  of  joint  tuberculosis  that  has 
given  us  more  satisfaction  than  this.  With  this  method  it  is  often  possible 
to  obtain  a  useful  foot  in  cases  which  formerly  could  only  be  relieved  by  an 
amputation. 

At  the  present  time  it  is  possible  to  obtain  artificial  limbs,  in  case  of 
amputation  at  the  lower  third  of  the  leg,  so  excellent  that  unless  one  can 
secure  a  good  result  after  a  resection  of  the  ankle  an  amputation  is  to  be 
preferred. 

TUBERCULOSIS   OF   THE  SHOULDER,   ELBOW   AND    OTHER   LARGE 

JOINTS. 

The  shoulder  joint  deserves  some  special  attention,  as  it  is  least  useful 
when  anchylosed,  and  consequently  an  operation  for  the  relief  of  tuber- 
culosis must  here  be  performed  in  a  manner  that  will  prevent  anchylosis. 
This  may  be  accomplished  by  stripping  back  the  periosteum  upon  the  shaft 
of  the  bone,  then  cutting  away  the  head,  together  with  two  or  three  centi- 
meters of  the  shaft  and  afterwards  covering  the  end  of  the  bone  with  the 
periosteum,  which  has  been  stripped  back,  together  with  some  fascia. 

The  Elbow  Joint. 

In  the  treatment  of  tuberculosis  of  the  clbozv  joint.,  the  social  and  eco- 
nomical condition  of  the  patient  must  be  considered.  An  anchylosis  at  a 
little  less  than  a  right  angle  will  produce  the  most  useful  and  the  most  pow- 
erful arm  for  a  laboring  man  or  a  mechanic,  but  the  awkward  position  will 
interfere  with  the  patient's  appearance.  If  one  desires  the  greatest  amount 
of  power  and  usefulness,  the  arm  should  be  dressed  at  a  little  less  than  a 
right  angle.  If  he  is  willing  or  desirous  to  sacrifice  these  qualities  for  the 
sake  of  obtaining  greater  beauty,  a  sufficient  amount  of  bone  should  be  re- 
moved to  insure  a  movable  joint,  the  ends  of  the  bones  being  again  covered 
with  soft  tissues. 

The  wrist  joint  should  be  dressed  as  nearly  straight  as  possible. 
The  Hip  Joint. 

The  hip  should  be  dressed  with  the  extremity  in  the  abducted  position, 
the  foot  extending  as  nearly  straightforward  as  possible,  both  inversion  and 
eversion  being  avoided.  This  precaution  considerably  overcomes  the  tend- 
ency to  shortening.  This  position  may  be  secured  by  means  of  a  plaster  of 
Paris  dressing,  or  by  a  weight-and-pulley  extension,  combined  with  the  use 
of  a  Hodgen's  splint  with  a  foot-piece  attachment,  which  will  insure  the 
vertical  position  of  the  foot. 

The  knee  should  be  dressed  in  a  slightly  flexed  position,  because  this 
secures  the  greatest  ease  in  walking. 

TUBERCULOSIS   OF  THE   SACRO-ILIAC  JOINT. 

Tuberculosis  in  this  joint  is  characterized  by  lameness,  which  at  first 
is  apparent  only  during,  or  more  frequently  the  day  after,  severe  exertion. 
A  misstep  or  a  quick  motion  is  likely  to  give  rise  to  pain.     The  patient 


Sl'RGERY    OK    THE    EXTREMITIES  86l 

usually  at  first  imagines  the  pain  to  be  located  in  the  hip,  and  percussion 
over  the  great  trochanter  is  apt  to  give  rise  to  pain.  There  is,  however,  no 
suffering  upon  motion  of  the  hip,  flexion,  extension  and  rotation  being 
normal  and  painless,  unless  the  motion  is  very  sudden  and  sufficiently  violent 
to  affect  the  ilium.  There  is  no  pain  upon  pressure  over  the  hip  joint,  but 
pain  is  present  when  pressure  is  made  over  the  sacro-iliac  articulation,  or 
when  compression  of  the  pelvis  is  made.  There  is  frequently  an  evening 
temperature. 
Technique. 

The  same  principles  obtain  here  in  the  treatment  of  tuberculosis  as  in 
the  other  joints.  In  many  hygienic  measures  and  rest  will  result  in  a  cure. 
Injection  with  iodoform  emulsion  gives  very  favorable  results,  and  should 
a  sinus  be  formed,  cauterization  frequently  produces  a  cure.  It  is  rather 
more  difficult  to  obtain  a  thorough  removal  of  all  the  diseased  tissue  where 
the  joint  is  extensively  involved  and  in  which  the  measures  mentioned  above 
have  failed  to  produce  a  cure,  than  in  tuberculosis  of  other  joints. 

In  these  cases  it  becomes  necessary  to  avoid  injuring  the  sciatic  nerve 
if  the  bone  is  so  extensively  diseased  as  to  approach  this  structure.  Our  own 
results  have  been  best  when  we  have  thoroughly  removed  all  of  the  diseased 
bone,  then  treated  the  cavity  with  strong  carbolic  acid,  then  with  alcohol  and 
then  tamponed  with  iodoform  gauze,  which  was  removed  after  a  week, 
when  the  cavity  was  treated  with  strong  tincture  of  iodine  and  sutured 
secondarily. 

The  patient  should  be  kept  in  bed  until  the  tissues  have  become  firm, 
because  motion  is  likely  to  disturb  the  newly-formed  tissues  and  cause  a 
recurrence. 
After-treatment  in  Cases  that  do  not  Heal  Primarily. 

Should  the  wound  not  heal  primarily,  the  sinuses  may  be  stimulated  by 
the  injection  of  strong  compound  tincture  of  iodine,  ninety-five  per  cent, 
carbolic  acid,  followed  with  strong  alcohol,  or  two  to  ten  per  cent,  solutions 
of  nitrate  of  silver  in  water. 

It  has  been  claimed  that  these  sinuses  will  heal  much  more  rapidly  if 
exposed  daily  to  the  influence  of  the  X-ray  for  a  period  of  fifteen  minutes  at 
a  distance  of  twelve  to  fifteen  centimeters.  We  have  not  tried  this  method 
in  a  sufficient  number  of  cases  to  be  entitled  to  an  opinion,  as  the  possibility 
of  coincidence  must  not  be  overlooked. 

In  a  number  of  instances  we  have  seen  rapid  and  permanent  healing 
after  touching  these  sinuses  thoroughly  with  the  actual  cautery,  the  point 
of  the  cautery  being  introduced  into  the  sinus,  permitting  the  heat  to  radiate 
to  the  surrounding  tissues.  This  is  much  better  than  to  attempt  to  touch 
all  of  the  infected  parts  directly.  A  rod  of  iron  the  size  of  a  lead-pencil, 
heated  to  red  heat  in  a  gas  or  alcohol  flame,  or  in  a  coal  fire,  or  a  tinsmith's 
heater,  serves  this  purpose  admirably.  Before  introducing  this  rod  into  a 
sinus,  the  direction  and  depth  of  the  latter  should  always  be  determined  by 
means  of  a  probe,  in  order  that  the  cautery  may  be  readily  introduced  in  a 
manner  to  insure  the  cauterization  of  the  sinus  throughout  its  course  without 
destroying  healthy  tissue. 

MIXED    INFECTION    IN  TUBERCULOUS  BONE  AND  JOINT  DISEASES. 

So  long  as  the  entire  infection  is  due  to  the  bacillus  of  tuberculosis,  the 


862  SURGERY    OF    THE    EXTREMITIES 

progress  of  the  disease  is  slow,  and  except  where  the  pressure  within  the 
capsule  of  the  joint  gives  rise  to  severe  pain,  the  patient  usually  does  not 
give  the  impression  of  being  very  ill,  unless  the  affection  is  complicated  with 
other  troubles,  such  as  tuberculosis  of  the  lungs.  If,  however,  the  disease 
becomes  complicated  by  infection  of  the  abscess  with  other  pathogenic  micro- 
organisms, the  condition  of  the  patient  at  once  becomes  much  more  serious. 
He  acquires  the  appearance  of  one  suffering  from  a  degree  of  sepsis,  de- 
pending upon  the  form  and  extent  of  the  infection,  and  his  general  state 
becomes  rapidly  more  grave,  usually  first  recognized  by  the  characteristic 
hectic  flush. 

It  is  a  singular  fact  which  has  been  constantly  demonstrated  clinically, 
that  a  tuberculous  abscess  may  open  spontaneously  and  discharge  through 
a  sinus  for  weeks,  months,  or  even  years,  without  becoming  infected  with 
other  pathogenic  micro-organisms,  while  a  similar  abscess  opened  by  an  in- 
cision may  become  infected  almost  at  once.  This  is  of  great  practical  im- 
portance, as  it  illustrates  the  point  that  by  a  simple  incision  the  surgeon  may 
in  a  moment  change  a  harmless  tuberculous  abscess  into  an  exceedingly 
harmful  mixed  infection. 

In  any  case,  then,  in  which  it  seems  impossible  to  remove  all  the  tuber- 
culous infection  and  change  a  tuberculous  abscess  into  a  clean  wound,  it 
seems  important  to  follow  a  method  which  removes  the  tuberculous  pus 
from  the  body  without  substituting  for  it  a  worse  condition.  This  may  be 
accomplished  by  lifting  up  a  fold  of  the  adjoining  healthy  skin  for  a  dis- 
tance of  three  to  five  centimeters  and  piercing  the  abscess  with  a  trocar  two 
or  three  millimeters  in  diameter,  permitting  the  tuberculous  pus  to  escape, 
and  then  injecting  the  cavity  with  a  ten  per  cent,  solution  of  iodoform  in 
glycerine,  sterilized.  (The  iodoform  should  be  put  into  an  open  bottle 
with  a  cotton  stopper,  and  placed  in  a  water  bath.  The  water  should  be 
permitted  to  boil  around  the  bottle  for  one  hour.  This  will  liberate  enough 
free  iodine  to  accomplish  the  sterilization). 

IODOFORM-GLYCERINE    INJECTON    OF   TUBERCULOUS    JOINTS. 

There  is  much  difference  of  opinion  regarding  the  value  of  iodoform- 
glycerine  mixtures  injected  into  the  cavity  of  tuberculous  joints.  Its  advo- 
cates show  a  large  number  of  perfect  and  permanent  recoveries  following 
this  form  of  treatment,  while  its  opponents  claim  that  all  of  these  cases  be- 
long to  a  class  which  would  have  healed  with  the  same  results  in  about  the 
same  time  had  they  been  treated  with  rest  and  ordinary  hygienic  measures. 
Both  the  advocates  and  the  opponents  of  this  form  of  treatment  represent 
some  of  the  ablest  and  most  experienced  surgeons,  and  we  are  not  prepared 
to  decide  which  faction  is  right,  although  our  o\vn  experience  is  strongly  in 
favor  of  this  method  in  the  early  treatment  of  tuberculosis  in  all  joints,  ex- 
cept the  hip.  There  are.  however,  several  points  in  the  technique  which 
should  be  rigorously  obeyed  : 

1.  The  trocar  should  never  be  plunged  directly  into  a  joint,  but  always 
obliquely  underneath  a  fold  of  skin,  so  that  a  valve  will  be  formed  when 
the  instrument  is  withdrawn,  which  will  prevent  the  infection  of  the  joint 
cavity  with  pathogenic  micro-organisms. 

2.  The  amount  of  manipulation   should  be  limited   so  as   to  prevent 
the    opening   of   lymph    spaces    through    which    secondary    infection    might 
occur. 


SURGERY    OF    THE    EXTREMITIES  863 

3.  The  amount  of  pressure  employed  in  injecting  the  solution  should 
be  moderate  in  order  to  avoid  rupturing  the  capsule  of  the  joint  and  forcing 
the  fluid,  together  with  tuberculous  contents  of  the  joint,  into  the  tissues 
surrounding. 

4.  If  the  treatment  does  not  result  in  distinct  benefit  to  the  patient 
after  five  or  six  applications,  from  one  to  two  weeks  apart,  it  should  be 
abandoned. 

5.  The  patient's  general  and  hygienic  surroundings  must  be  improved 
to  a  favorable  standard. 

6.  As  much  as  possible  of  the  fluid  contained  in  the  joint  should  be 
withdrawn  before  the  injection  is  made. 

/.  Except  in  the  shoulder  and  sacro-iliac  joints,  an  Esmarch  con- 
strictor should  be  applied  before  the  joint  is  tapped,  and  left  in  place  until  a 
large  dressing  has  been  fitted  and  held  in  position  by  a  snug  bandage,  which 
will  prevent  hemorrhage  into  the  joint. 

This  last  precaution  is  not  generally  employed,  but  we  are  confident 
that  it  is  of  distinct  benefit. 

In  applying  the  constrictor  for  this  purpose  the  same  precaution  should 
be  taken  against  injuring  the  large  nerves  as  in  other  operations.  A  large 
rubber  tube  or  a  broad  rubber  bandage  should  be  used  in  preference  to  the 
narrow  rubber  band  usually  employed.  If  a  small  rubber  tube  or  a  narrow 
band  is  used,  the  extremity  should  first  be  protected  by  wrapping  with  a 
towel,  folded  upon  itself  at  least  four  times. 

In  inserting  the  trocar  into  the  various  joints,  aside  from  carefully  se- 
curing a  valve  formation  of  the  canal,  the  surgeon  must  avoid  injuring  im- 
portant anatomic  structures  in  the  vicinity  of  the  joint,  and  the  point  of  the 
trocar  must  be  directed  so  that  it  will  not  injure  any  joint  surface. 

In  the  smaller  joints  a  very  small  amount  of  the  solution  may  suffice, 
the  quantity  depending  upon  the  tension  caused  by  the  fluid  injected,  which 
should  never  be  sufficiently  great  to  endanger  the  capsule  or  produce  severe 
pain.  In  the  wrist  joint  the  introduction  of  the  fine  trocar  used  is  usually 
not  followed  by  the  evacuation  of  any  fluid,  and  here  the  injection  of  two 
to  four  cubic  centimeters  will  often  be  followed  by  perfect  results. 

In  the  knee  joint  it  is  often  possible  to  withdraw  several  ounces  of  fluid, 
and  in  these  cases  it  is  safe  to  inject  as  high  as  thirty  or  forty  cubic  centi- 
meters of  the  iodoform-glycerine  solution. 

In  the  treatment  of  psoas  and  iliac  abscesses  much  larger  quantities  of 
tuberculous  pus  are  frequently  withdrawn  through  the  trocar,  and  it  is 
safe  to  inject  from  thirty  to  fifty  cubic  centimeters  of  a  ten  per  cent,  solu- 
tion of  iodoform  in  glycerine. 

To  prevent  too  great  tension  in  injecting  this  solution  into  tuberculous 
joints,  it  is  well  to  attach  a  soft  rubber  tube  to  the  trocar  with  one  end,  and 
to  a  glass  syringe  holding  thirty  cubic  centimeters  with  the  other,  and  then 
pour  the  solution  into  the  glass  syringe  and  introduce  the  plunger  after  the 
rubber  tube  and  the  trocar  have  become  filled  with  the  solution  sponta- 
neously. 

In  forcing  in  the  plunger,  if  the  pressure  becomes  too  great,  the  inter- 
vening rubber  tube  will  dilate  before  a  sufficient  amount  of  pressure  has 
been  exerted  to  injure  the  capsule  of  the  joint.  In  injecting  the  large  joints 
a  large  trocar  is  used,  but  in  the  smaller  joints  the  trocar  should  be  just 
large  enough  to  permit  the  transmission  of  the  iodoform  mixture. 

Until  the  pain  has  subsided  the  patient  should  be  kept  at  rest,  then  a 


OF  THE  EXTREMITIES 


moderate  amount  of  exercise  is  useful.    The  injection  is  repeated  every  one 
to  two  weeks  at  first,  and  less  frequently  later. 

New  Preparations. 

During  the  past  year  we  have  frequently  used  two  mixtures  in  place 
of  the  above  one  of  iodoform  in  the  treatment  of  tuberculous  joints  and 
tuberculous  abscesses.  These  mixtures  have  been  used  with  remarkable 
success  by  Professor  Calot,  of  France,  and  we  are  able  to  confirm  his  ob- 
servations. They  are  applied  precisely  like  the  above  iodoform  mixture. 
No.  i  is  used  in  all  cases  in  which  the  joint  contains  liquid  accumulations, 
while  No.  2  is  used  where  the  accumulation  is  of  a  consistency  too  thick 
to  be  evacuated  through  the  trocar,  and  will  have  the  effect  of  liquefying 
the  accumulation  within  a  week  or  two,  when  the  treatment  should  be  con- 
tinued with  formula  No.  i. 

Formula  No.  i. 

Iodoform 5  parts. 

Ether 10 

Guaicol    2       " 

Creosote    2       " 

Sterile  olive  oil 100       " 

Of  this  from  ten  to  twenty  c.  c.  arc  injected  into  tuberculous  joints  or 
tuberculous  abscess  cavities  after  the  fluid  has  been  evacuated..  This  is  re- 
peated once  a  week  at  first  and  less  frequently  later. 

Formula  No.  2. 

Camphor    2  parts. 

Thymol   i       " 

Of  this  solution  five  c.  c.  are  injected  once  a  week  until  the  accumula- 
tion in  the  joint  becomes  liquid. 

Beck's  Bismuth  Paste. 

In  all  cases  in  which  operations  are  followed  by  the  persistence  of 
sinuses  Beck's  bismuth  paste,  consisting  of  one  part  of  arsenic-free  sub- 
nitrate  of  bismuth  in  two  parts  of  sterile  yellow  vaseline,  should  be  injected 
and  the  external  wound  closed  with  a  gauze  plug.  We  have  heated  the 
paste  to  one  hundred  and  ten  degrees  F.,  and  thought  that  this  facilitated 
the  thorough  distribution  of  the  substance  to  all  parts  of  the  sinuses,  but 
others  have  applied  it  cold  with  apparently  excellent  results. 

Care  should  be  taken  to  inject  just  enough  to  fill  all  parts  of  the 
sinuses,  but  not  enough  to  cause  a  rupture  of  any  of  the  canals. 

The  injection  should  be  made  daily  at  first  and  less  frequently  later.  In 
case  of  large  cavities  it  is  best  not  to  fill  the  entire  cavity  at  first  until  the 
patient's  tolerance  has  been  established.  In  case  of  poisoning  the  patient's 
gums  will  become  sore  and  later  a  black  line  will  develop.  The  patient  will 
feel  depressed.  He  may  or  may  not  have  an  elevation  of  temperature. 

In  these  cases  the  sinuses  or  cavities  should  be  filled  writh  olive  oil 
heated  to  one  hundred  and  ten  degrees  F.,  and  drainage  tubes  should  be 
inserted  for  the  free  evacuation  of  the  paste  diluted  with  the  hot  oil.  This 
should  be  repeated  daily  until  the  patient's  condition  has  improved. 

With  fair  caution,  there  is  little  danger  from  poisoning,  but  the  possi- 
bility should  always  be  remembered. 


SURGERY  OF  THE  EXTREMITIES  865 

Beck's  paste  is  one  of  the  most  valuable  remedies  ever  introduced  into 
the  treatment  of  tubercular  sinuses,  and  the  results  obtainable  by  its  care- 
ful use  are  most  satisfactory. 

THE  TREATMENT  OF  CRUSHING  INJURIES  OF  THE  EXTREMITIES. 

In  the  treatment  of  crushing  injuries  and  lacerated  wounds  of  the  ex- 
tremities, the  point  of  first  importance  lies  in  securing,  as  nearly  as  possible, 
aseptic  conditions. 

It  is  interesting  to  observe  the  marked  difference  in  the  difficulty  one 
experiences  in  obtaining  such  a  result  in  different  classes  of  patients.  For 
persons  who  are  strong  and  healthy,  who  live  in  hygienic  surroundings  and 
are  cleanly  in  their  habits,  it  is  relatively  easy  to  secure  an  aseptic  wound 
after  one  of  these  injuries.  This  is  ordinarily  the  condition  of  railroad 
employes,  skilled  mechanics  in  factories,  men  employed  in  the  iron  mines 
in  the  northern  part  of  this  country,  and  in  farmers;  but  not  that  of  the 
shiftless  who  are  injured  in  the  streets.  Persons  who  have  been  employed 
about  horses  are  more  likely  to  suffer  from  tetanus  than  others.  This  is 
also  true  of  those  who  have  been  injured  upon  the  highways. 

The  fact  that  mechanics  are  likely  to  have  their  hands  covered  with  oil 
and  particles  of  iron  and  other  metal  does  not  indicate  that  it  will  be  diffi- 
cult to  secure  aseptic  conditions,  as  this  form  of  dirt  is  usually  very  clean 
from  a  surgical  standpoint.  The  oil  contained  in  this  dirt  has  in  itself  an 
inhibitory  effect  upon  the  development  of  micro-organisms. 

Tf  the  injury  be  severe,  it  is  usually  best  to  anesthetize  the  patient,  be- 
cause this  will  enable  the  surgeon  to  be  more  thorough  in  cleansing  the 
wound.  If  it  is  necessary  to  transport  the  patient  some  distance  to  his 
home  or  to  a  hospital,  before  it  is  possible  to  proceed  with  the  cleansing 
of  the  wound,  it  is  best  to  apply  about  the  extremity  a  compress  of  aseptic 
gauze,  wrung  out  of  an  antiseptic  solution.  For  this  purpose  i  in  2,000 
of  corrosive  sublimate  in  water  is  usually  most  convenient,  because  it  can 
be  prepared  wherever  it  is  possible  to  obtain  sterile  water,  provided  the 
surgeon  has  with  him  some  tablets  of  definite  size.  Any  one  of  a  number 
of  other  antiseptic  solutions  may  be  substituted,  such  as  three  per  cent, 
carbolic  acid,  saturated  solution  of  boric  acid,  or  thirty  per  cent,  solution 
of  alcohol.  If  water  is  not  available  it  will  suffice  to  cover  the  wound  with 
aseptic  gauze  after  the  hemorrhage  has  been  controlled,  which  is,  of  course, 
always  the  first  step  necessary. 

Control  of  Hemorrhage. 

If  the  vessel  can  be  caught  with  hemostatic  forceps  and  ligated,  such 
method  is  most  convenient.  If  this  is  not  possible  a  suture  may  be  passed 
around  the  bleeding  point,  and  the  same  ligated.  If  there  is  simply  oozing 
from  a  large  surface,  this  may  be  controlled  by  pressure,  by  applying  a 
gauze  tampon,  to  be  held  in  place  by  a  roller  bandage. 

In  some  instances,  it  is  best  simply  to  keep  the  extremity  in  an  elevated 
position  until  an  elastic  constrictor  can  be  applied,  and  the  wound  disin- 
fected and  the  vessel  ligated. 

If  the  palmar  arch  has  been  injured,  and  the  hemorrhage  cannot  be 
controlled  by  the  application  of  ligatures  or  hemostatic  forceps,  the  arm 
may  be  elevated  permanently  for  several  days  by  applying  rubber  adhesive 
straps  to  the  forearm,  attaching  these  to  a  cross-piece,  and  to  this  a  cord, 


866  SURGERY    OF    THE    EXTREMITIES 

which  passes  over  a  pulley  suspended  to  the  ceiling,  or  upon  a  frame  to  a 
weight,  which  will  keep  the  extremity  elevated  comfortably.  An  elastic 
constrictor  should  never  be  kept  in  position  for  any  lengthened  period.  It 
is  not  safe  for  more  than  two  or  three  hours  at  a  time,  and  even  this  may 
give  rise  to  gangrene  in  some  cases,  especially  if  the  patient  be  advanced  in 
age  and  suffering  from  endarteritis. 

Usually  the  disinfection  may  be  thoroughly  accomplished  in  less  than 
half  an  hour. 

Disinfection. 

If  the  extremity  is  covered  with  black,  oily  dirt,  common  in  mechanics, 
it  is  best  to  first  wash  with  kerosene  or  some  other  form  of  coal  oil.  Then 
soap  and  hot  water,  with  a  piece  of  gauze,  should  be  thoroughly  used,  then 
sterile  water,  then  some  antiseptic  solution,  such  as  i  to  2,000  corrosive  sub- 
limate, or  three  per  cent,  carbolic  acid  in  hot  water. 

If  there  is  still  some  doubt,  the  entire  wound  may  be  washed  with 
ninety-five  per  cent,  carbolic  acid  for  one  to  three  minutes  and  then  with 
strong  alcohol  until  the  tissues  have  a  normal  appearance. 

If  the  wound  has  been  covered  with  street  dust,  or  the  patient  has 
worked  among  horses,  it  seems  best  to  apply  strong  compound  tincture  of 
iodine  to  the  entire  surface,  and  then  rub  iodoform  over  the  whole  part, 
because  it  is  claimed  that  this  treatment  will  prevent  infection  with  the 
tetanus  bacillus,  and  our  own  observations  appear  to  confirm  this  theory. 
There  is,  however,  no  doubt  but  that  the  point  of  greatest  importance  is 
the  thoroughness  with  which  the  wound  is  scrubbed,  so  that  all  particles  of 
dirt  may  be  removed  mechanically. 

If  a  hand  or  finger,  or  any  other  part  of  an  extremity,  has  been  en- 
tirely crushed  off,  the  remaining  stump  may  be  trimmed  up  at  once,  care 
being  taken  to  sacrifice  as  little  tissue  as  possible ;  but  in  the  vast  majority 
of  crushing"  iniuries  it  is  much  better  for  the  patient  if  only  the  complete 
disinfection  is  accomplished  at  once,  and  the  wound  left  wide  open,  so  that 
the  tissues  may  have  free  drainage;  this  will  aid  in  preventing  infection, 
and  will  favor  the  recovery  of  tissues  which  seem  hopelessly  damaged  at 
the  time  of  the  injury  or  first  examination.  Leaving  the  wound  without 
suturing  until  the  tissues  have  recovered,  also  favors  return  circulation,  be- 
cause none  of  the  vessels  will  then  be  constricted  by  stitches.  Many  times 
a  very  useful  skin  flap  will  become  gangrenous  because  of  the  venous  stasis 
resulting  from  the  application  of  sutures  directly  after  an  injury  has  oc- 
curred, and  before  the  circulation  has  become  re-established. 

For  the  reasons  mentioned,  primary  amputations  after  crushing  in- 
juries are  but  rarely  indicated. 

It  would,  however,  be  eminently  unsafe  to  leave  these  crushed  tissues 
attached  to  an  extremity  if  the  surgeon  were  careless  in  his  disinfection, 
but  if  he  is  thorough  it  will  result  in  great  benefit  to  the  patient.  If,  how- 
ever, the  crushed  tissue  is  septic  when  the  patient  comes  under  the  sur- 
geon's care,  the  conditions  are  entirely  changed,  for  then  not  only  the 
crushed  portion  may  be  lost,  but  the  infection  may  result  in  a  pyemia  and 
the  patient's  life  endangered.  Here  the  plan  of  treatment  should  be  fol- 
lowed that  was  described  in  connection  with  septic  infections  of  the  ex- 
tremities. After  the  infection  has  subsided,  an  operation  may  be  performed, 
which  will  be  indicated  by  the  condition  of  the  tissues.  Any  necrotic  por- 
tions will  have  been  removed  from  time  to  time  while  the  treatment  has 
caused  the  septic  infection  to  subside. 


SURGERY    OF    THE    EXTREMITIES  867 

If,  however,  the  patient  comes  under  the  surgeon's  care  reasonably 
early,  the  danger  of  a  serious  infection  is  very  slight,  provided  the  wound 
be  thoroughly  disinfected  and  left  wide  open,  as  mentioned  above,  so  that 
drainage  will  be  good,  and  the  return  circulation  favored  by  elevating  the 
extremity,  and  complete  rest  of  the  extremity  is  enforced,  so  that  any  un- 
avoidable slight  infection  will  not  be  pumped  through  the  lymphatics  in  a 
proximal  direction. 

In  case  any  pockets  of  local  infection  have  been  formed,  these  should 
be  laid  wide  open,  the  incision  in  each  case  being  carried  parallel  with,  and 
not  through,  the  important  anatomical  structures  in  the  part  involved. 

If  there  are  any  projecting  shreds  of  tissue  that  cannot  possibly  be 
utilized  at  any  future  time,  these  should  be  cut  away,  but  no  tissue,  no  mat- 
ter how  irregular,  which  might  be  used  in  a  plastic  way  should  be  sacrificed 
until  it  is  known  just  how  much  may  be  saved. 

Too  much  stress  has  been  laid  upon  the  importance  of  the  destruction 
of  large  arteries  or  veins  in  cases  where  it  seemed  wise  to  amputate  at 
once,  under  the  impression  that  gangrene  would  certainly  occur  from  the 
destruction  of  important  vessels.  There  are  many  instances  in  which  anom- 
alies have  existed,  which  could  not  be  determined  at  the  time  of  the  injury, 
or  in  which  there  has  been  an  unexpected  degree  of  compensatory  circula- 
tion, so  that  an  extremity  which  was  theoretically  doomed  could  be  saved 
entirely,  or  to  a  great  extent.  It  should,  however,  be  remembered  that  one 
may  take  these  chances  only  wrhen  it  is  possible  to  so  thoroughly  disinfect 
these  wounds  that  we  need  not  fear  a  dangerous  infection  by  a  waiting,  con- 
servative plan  of  treatment.  If  we  are  not  competent  to  secure  this  con- 
dition, then  we  must  abide  by  the  rules  laid  down  at  a  time  when  all  were 
equally  handicapped. 

In  case  a  joint  of  considerable  size  has  been  opened,  the  course  of  treat- 
ment to  be  followed  will  depend  largely  upon  the  judgment  of  the  sur- 
geon. If  it  seems  likely  from  the  conditions  present  that  an  infection  has 
taken  place,  it  will  be  safest  to  lay  the  joint  widely  open,  being  careful,  how- 
ever, not  to  increase  the  infection,  and  to  disinfect  it  in  the  same  thorough 
manner  as  the  other  tissues.  If  it  seems  fairly  certain  that  no  infection  has 
taken  place,  then  it  will  lie  best  to  disinfect  the  wound  in  the  joint  as  de- 
scribed above,  and  then  to  close  the  latter  with  a  few  catgut  sutures  and 
leave  the  remaining  wound  wide  open.  Too  much  importance  cannot  be 
given  the  fact  that  it  is  an  easy  matter  to  infect  an  open  joint,  and  that 
consequently  it  should  receive  the  first  attention,  and  should  then  be  guarded 
carefully  until  the  remaining  portions  of  the  wound  have  been  thoroughly 
asepticized. 

What  has  been  said  of  the  larger  joints  is  true  of  the  metatarsal  and 
phalangeal  joints,  but  it  is  much  less  difficult  to  disinfect  these,  and  conse- 
quently there  is  less  danger  to  the  patient. 

CRUSHING  INJURIES  TO  BONES. 

The  large  bones  have  been  considered  in  speaking  of  compound  frac- 
tures, and  the  same  principles  should  be  carried  out  in  the  treatment  of 
crushing  injuries  of  the  smaller  bones;  fragments  which  are  entirely  loose 
should  be  removed,  and  irregular  ends  should  be  trimmed  with  bone-cutting 
forceps.  Rough  ends  of  bones  into  which  dirt  has  been  ground  so  thor- 
oughly that  it  cannot  be  removed  should  be  trimmed  in  the  same  manner. 


868  SURGERY  OF  THE  EXTREMITIES 

Dressing. 

If  it  is  convenient,  the  following  dressing  should  be  employed  in 
wounds  of  the  extremities.  A  saturated  solution  of  boric  acid  in  hot  water, 
to  which  one-third,  by  volume,  of  strong  commercial  alcohol  has  been 
added,  should  be  used  to  moisten  the  aseptic  gauze  which  is  applied  directly 
to  the  wound.  If  there  is  any  reason  for  fearing  tetanus  infection,  a  few 
layers  nearest  the  wound  should  be  composed  of  iodoform  gauze.  Over 
this  a  thick  layer  of  cotton  is  applied,  and  over  all  a  soft  roller  bandage. 
If  there  is  an  increase  in  temperature  the  entire  dressing  should  be  sur- 
rounded by  a  rubber  sheet,  and  from  a  pint  to  a  quart  of  the  same  solution 
poured  into  the  dressing  every  three  to  six  hours.  The  quantity  should  be 
regulated  by  the  size  of  the  dressing,  and  the  rapidity  with  which  the  mois- 
ture disappears. 

If  it  is  not  possible  to  apply  a  moist  dressing  the  surface  should  be 
lightly  powdered  with  iodoform.  It  should  then  be  covered  with  iodoform 
gauze,  then  with  sterile  gauze,  then  with  cotton. 

The  dressings  should  be  applied  in  such  manner  that  they  may  be 
opened  without  causing  unnecessary  pain  to  the  patient,  so  that  the  wound 
can  be  inspected  regularly. 

If  there  is  a  tendency  to  the  occurrence  of  necrosis  the  wound  should 
be  inspected  every  day,  but  if  at  the  first  dressing  it  appears  that  the  nutri- 
tion is  good,  then  it  will  be  best  to  disturb  it  as  seldom  as  possible  until  it 
seems  to  have  recovered  sufficiently  to  make  the  operation  for  final  repair 
of  the  injury  proper.  The  condition  of  the  tissues  will  determine  this.  If 
there  are  small  points  of  necrosed  tissue,  it  is  usually  best  to  wait  until  the 
circulation  in  the  adjoining  structures  has  been  improved  to  such  an  extent 
that  no  further  necrosis  need  be  feared.  If  the  tissues  are  trimmed  too 
early,  one  is  likely  to  remove  portions  that  might  be  utilized  to  advantage  in 
repairing  defects. 

In  making  the  final  operation,  it  is  far  more  important  that  the  ultimate 
result  be  satisfactory  than  that  the  appearance  at  the  conclusion  of  the  op- 
eration be  pleasing. 

Too  often  a  portion  of  an  extremity  is  sacrificed  in  order  to  obtain  a 
handsome  stump.  The  absence  of  skin  from  one-half  or,  in  some  instances, 
even  three-fourths  of  the  portion  of  the  extremity  involved,  no  longer  makes 
an  amputation  imperative,  because  the  surface  can  be  covered  with  skin- 
grafts,  and  if  this  is  done  before  the  wound  has  existed  long  enough  to 
produce  a  great  amount  of  cicatricial  tissue  the  extremity  frequently  be- 
comes very  useful.  The  fact  that  nerves  have  been  destroyed  for  a  dis- 
tance not  to  exceed  ten  or  twelve  centimeters  does  not  make  an  amputa- 
tion imperative.  Neither  is  this  the  case  if  tendons  to  the  same  length  have 
been  destroyed,  because  these  structures  may  be  grafted,  and  although  this 
is  not  always  successful  it  so  frequently  results  in  a  satisfactory  functional 
result  that  it  is  quite  worth  while  to  make  the  attempt. 

In  covering  large  surfaces  with  skin-grafts,  the  method  which  has 
been  described  should  be  carefully  followed,  for  it  will  result  in  a  substan- 
tial, pliable,  soft  and  durable  covering,  instead  of  the  thin,  shiny,  adherent 
skin  one  encounters  so  frequently  in  cases  that  have  been  grafted  by  differ- 
ent methods. 

The  old  rule  of  preserving  the  head  of  the  metatarsal  bone  invariably, 
if  at  all  possible,  and  the  head  of  the  metacarpal  bone  in  men  who  work 
with  their  hands,  should  be  borne  in  mind.  It  is  wise  to  do  this  even  if 


SURGERY    OF    THE    EXTREMITIES  869 

there  is  not  sufficient  skin  to  cover  the  bone.  This  precaution  adds  greatly 
in  preserving  the  usefulness  of  the  hand  or  foot. 

A  very  small  portion  of  a  hand  or  wrist  is  valuable  to  the  patient,  and 
every  effort  should  be  used  to  preserve  as  much  as  possible  of  the  upper 
extremity. 

In  the  lower  extremity  this  is  also  true,  unless  the  ankle  joint  is  in- 
volved in  the  injury  and  the  entire  foot  destroyed.  In  such  case  an  ampu- 
tation through  the  lower  third  of  the  leg  will  enable  the  patient  to  obtain 
an  artificial  limb,  with  which  he  can  walk  comfortably  and  gracefully. 

Above  this  point  it  is  again  necessary  to  save  as  much  of  the  extremity 
as  possible. 

AMPUTATIONS. 

In  making  amputations,  the  surgeon  should  strive  to  obtain  a  stump  in 
which  the  scar  is  not  adherent  to  the  end  of  the  bone,  so  that  subsequently 
there  may  not  be  produced  an  ulcer  at  the  end  of  the  stump,  due  to  the 
fact  that  the  fixed  scar  results  in  constant  pressure  upon  a  given  point. 

The  flaps  should  be  cut  so  that  the  scar  will  be  exposed  to  as  little 
pressure  as  possible.  This  is  accomplished  most  readily  by  making  the 
flaps  of  different  length. 

The  sharp  angles  of  the  ends  of  bones  should  be  trimmed  away  for  the 
same  purpose. 

If  the  patient  be  a  laborer,  who  is  compelled  to  walk  on  the  soft  ground 
or  lift  heavy  weights,  it  is  often  desirable  to  obtain  for  him  a  stump  which 
will  support  his  body  directly  upon  its  end.  This  can  be  accomplished  only 
by  constructing  a  covering  layer  of  bone  for  the  end  of  the  stump,  effected 
by  making  the  first  section  a  sufficient  distance  beyond  the  point  at  which 
the  final  section  is  to  be  made,  so  that  when  the  second  section  is  made,  a 
plate  of  the  projecting  portion  can  be  placed  across  the  sawed  end  as  a 
covering.  The  flattest  surface  of  the  bone  is  then  chosen,  and  a  thin  plate 
sawed  upward  to  the  point  at  which  the  ultimate  section  is  to  be  made.  The 
periosteal  covering  of  this  part  is  left  in  place,  but  the  periosteum  of  the 
remaining  portion  of  the  bone  is  stripped  upward  and  protected  while  this 
portion  of  the  bone  is  being  sawed  off  transversely. 

The  attachment  of  the  plate  which  is  left  standing  will  be  weakened 
by  a  few  strokes  of  the  saw,  care  being  taken  not  to  injure  the  periosteum. 
The  remaining  portion  is  then  broken  and  the  plate  which  has  been  thus 
formed  is  placed  across  the  end  of  the  bone  and  sutured  in  position  by 
means  of  a  few  stitches  of  catgut  passed  through  the  periosteum. 

The  operation  is  completed  in  the  ordinary  way. 

At  the  lower  end  of  the  femur  this  method  can  be  accomplished  by 
making  a  transverse  section  through  the  condyles  and  sawing  off  the  lower 
surface  of  the  patella. 

In  the  upper  extremity,  there  is,  of  course,  never  any  occasion  for 
bearing  weight  upon  the  end  of  the  stump,  hence  there  is  no  necessity  for 
special  provision  against  having  the  scar  opposite  the  end  of  the  stump. 

For  this  reason  the  circular  method  has  become  popular  for  amputation 
of  the  upper  extremity. 

It  is  very  important  that  the  flaps  be  cut  long  enough  to  prevent  ten- 
sion. The  larger  nerves  should  be  found,  drawn  down  and  cut  off  two  to 
five  centimeters  from  the  end  of  the  stump  in  order  to  prevent  their  ad- 
hesion to  the  scar.  At  the  end  of  a  nerve  of  considerable  size,  it  is  best  to 


870  SURGERY    OF    THE    EXTREMITIES 

make  a  V-shaped  section,  which  will  permit  the  two  ends  to  fall  together 
and  form  a  rounded  point,  which  has  a  tendency  to  prevent  the  formation 
of  an  amputation  neuroma. 

The  sutures  should  be  drawn  only  tightly  enough  to  secure  coaptation. 

Hemorrhage  should  be  controlled  very  accurately,  so  that  the  flaps 
will  not  be  separated  by  blood  clots. 

In  case  the  wound  is  not  perfectly  dry,  or  if  one  cannot  be  absolutely 
certain  that  it  is  aseptic,  drainage  should  be  employed.  This  may  be  ac- 
complished by  the  introduction  of  rubber  drainage  tubes,  or  by  passing 
through  the  wound  a  number  of  strands  of  catgut  or  silkworm  gut. 

The  greatest  care  should  be  exercised  to  prevent  infection,  as  this 
favors  the  formation  of  pressure  neuromata  and  adherent  scars,  both  con- 
ditions being  sure  to  cause  great  discomfort,  if  not  complete  disability. 

The  stump  should  be  dressed  with  a  sufficient  amount  of  gauze  and  cot- 
ton to  permit  the  application  of  mild,  uniform  pressure  by  means  of  a  soft 
roller  bandage. 

Rest  is  one  of  the  most  important  elements  necessary  for  perfect  heal- 
ing, and  this  may  be  most  readily  attained  by  applying  a  splint  in  every  case 
in  which  it  is  possible.  The  extremity  should  be  elevated,  in  order  to  favor 
return  circulation. 

In  many  of  these  cases,  a  much  better  functional  result  may  be  ob- 
tained by  simply  trimming  away  the  portions  which  cannot  be  utilized,  after 
the  circulation  in  the  flaps  has  recovered  sufficiently,  and  then  suturing  the 
remaining  portions  in  the  best  position  possible,  and,  later,  covering  the  re- 
maining surfaces  with  skin-grafts,  than  if  a  complete  operation  is  performed 
at  once.  It  is  often  possible  to  preserve  a  considerable  portion  of  the  ex- 
tremity which  would  otherwise  have  been  sacrificed.  Many  times  one  or 
two  phalanges  of  a  finger  may  be  saved  in  this  manner,  which  is  a  very  im- 
portant matter,  especially  to  a  workingman. 

SENILE  GANGRENE. 

Gangrene  not  directly  resulting  from  severe  traumatism  or  septic  in- 
fection is  most  commonly  due  to  a  thrombosis  of  one  or  more  arteries.  In 
aged  persons  this  is  usually  dependent  upon  arterio-sclerosis.  Its  imme- 
diate location  is  determined  by  an  acute  endarteritis  which  may  be  the  result 
of  a  slight  traumatism  or  exposure  to  cold,  not  sufficient  in  either  case  to 
affect  blood  vessels  in  their  normal  condition. 

The  patient  feels  a  severe  pain,  usually  along  the  course  of  one  of  the 
larger  arteries  in  one  of  his  lower  extremities.  Upon  examination,  the  part 
of  the  extremity  beyond  the  region  of  pain  is  cold  to  the  touch.  For  a  short 
time  after  the  beginning  of  the  difficulty  the  skin  is  white;  later  it  becomes 
red,  still  later  purple,  and  then  black.  Before  it  becomes  black  numerous 
blebs  usually  form.  The  area  affected  is  at  first  not  circumscribed,  but 
there  is  a  gradual  departure  from  the  normal  appearance  toward  the  prox- 
imal end  of  the  extremity,  which  changes  into  the  perfectly  black  at  the 
distal  end.  The  latter  condition  may  extend  over  but  a  small  portion  of  one 
toe,  or  it  may  include  one  or  more  of  these  extremities,  or  the  entire  foot, 
or  a  large  portion  of  the  leg. 

Usually  the  morbidity  progresses  upwards  as  the  thrombus  increases 
in  extent.  Alany  times  the  circulation  through  the  smaller  branches  of 
arteries  is  increased  because  the  communicating  branches  are  dilated,  and 


SURGERY    OF    THE    EXTREMITIES  87! 

then  the  condition  will  subside  and  portions  which  have  not  yet  become 
black,  but  which  seemed  to  approach  that  state,  may  recover  partly  or  com- 
pletely. This  tendency  may  be  favored  by  keeping-  the  extremity  slightly 
elevated,  to  encourage  return  circulation,  and  by  keeping  the  temperature 
as  nearly  normal  as  possible  by  applying  artificial  heat. 

In  the  meantime  the  part  should  be  kept  covered  with  an  aseptic  dress- 
ing-, which  will  prevent  infection  from  without.  It  is  well  to  wash  the  skin 
with  strong  alcohol  each  day,  when  a  fresh  dressing  is  applied. 

For  a  number  of  years  the  opinion  has  prevailed  among  surgeons  that 
it  is  best  to  make  an  amputation  high  up  on  the  extremity  early  in  such 
an  attack,  in  order  to  prevent  the  thrombosis  from  extending  upward  into 
the  common  iliac  artery  and  thence  to  the  same  vessel  on  the  opposite  side. 
It  seems  that  this  theory  cannot  be  supported  by  our  own  experience,  and 
consequently  we  advise  the  plan  which  has  been  found  most  satisfactory  in 
our  experience.  It  is  to  be  borne  in  mind,  however,  that  this  is  an  open 
question  as  yet,  and  that  the  plan  here  advised  should  consequently  not  be 
accepted  as  final. 

Our  patients  have  fared  best  when  we  have  kept  the  extremity  as 
aseptic  as  possible  until  the  line  of  demarcation  had  formed.  If  this  oc- 
curred at  any  point  at  which  an  amputation  would  result  in  a  useful  stump 
that  point  was  chosen  for  the  amputation.  If  a  more  useful  stump  could 
be  secured  by  making  the  amputation  higher  up  then  that  location  was  se- 
lected. 

In  making  the  amputation  three  requirements  are  observed : 

1.  The  extremity  is  elevated  in  order  to  make  the  field  of  operation 
bloodless  by  the  aid  of  gravitation.     It  is  kept  in  this  position  throughout 
the  operation,  no  constrictor  of  any  kind  being  employed. 

2.  The  flaps  are  made  ample,  so  that  they  cover  the  end  of  the  stump 
•vithout  the  slightest  amount  of  stretching. 

3.  No  sutures  are  employed   for  closing  the  wound,  the  flaps  being 
simply  placed  in  apposition  and  a  large,  rather  loose  dressing  applied  to  hold 
them  in  place. 

The  extremity  is  then  placed  in  a  slightly  elevated  position  to  favor  re- 
turn circulation.  It  will  be  seen  that  these  precautions  are  intended  to  pre- 
vent impairment  of  the  circulation,  which  is  already  greatly  hampered. 

By  following  these  precautions  the  results  have  been  very  satisfactory. 

After  the  circulation  has  become  thoroughly  established  in  the  flaps  it 
is  safe  to  apply  secondary  sutures  at  any  point  at  which  satisfactory  union 
has  not  taken  place,  or  where  the  coaptation  of  the  skin  has  not  been  ef- 
fected. 

It  is  important  that  the  patient  be  guarded  against  exposing  himself  in 
the  future  to  the  circumstances  which  acted  as  exciting  causes  of  the  diffi- 
culty. He  should  avoid  traumatism.  cold  and  infection.  His  general  hy- 
gienic conditions  should  be  improved  and  his  diet  regulated. 

DIABETIC  GANGRENE. 

It  has  been  observed  that  an  operation  upon  a  patient  suffering  from 
diabetic  gangrene  is  likely  to  be  followed  by  death  within  a  very  few  days, 
in  fact,  usually  within  two  days,  with  the  symptoms  of  diabetic  coma.  This 
fact  has  induced  many  surgeons  to  absolutely  advise  against  surgical  inter- 
vention in  cases  of  gangrene  complicated  bv  diabetes.  This  course  will 


8/2  SURGERY    OF    THE    EXTREMITIES 

disable  the  patient  for  a  long  period  of  time,  if  not  permanently,  and  it  ex- 
poses him  to  the  danger  of  an  intercurrent  septic  infection,  which  is  very 
likely  to  occur  sooner  or  later,  because  the  tissues  in  diabetic  patients  seem 
especially  well  suited  as  culture  media  for  pathogenic  micro-organisms. 

But  in  a  large  proportion  of  these  cases  it  is  not  necessary  to  follow 
this  plan  of  denial  of  surgical  relief,  for  with  proper  precautionary  treat- 
ment, it  is  possible  to  improve  the  condition  to  such  an  extent  that  they  will 
bear  amputations  almost  as  well  as  patients  suffering  from  uncomplicated 
senile  gangrene. 

The  important  features  of  such  preparatory  treatment  consist  in  giv- 
ing large  quantities  of  distilled  water,  from  two  to  six  quarts  per  day,  until 
the  thirst  has  entirely  disappeared,  which  is  usually  accomplished  within 
two  weeks,  and  after  this  the  quantity  of  distilled  water  is  regulated  by  the 
patient's  desire.  A  moderate  anti-diabetic  diet  is  given — a  diet  which  should 
be  free  from  sugar,  poor  in  starches,  but  in  which  vegetables  may  be  eaten 
very  freely.  The  diet  should  further  contain  considerable  fat,  especially 
olive  oil,  if  it  is  agreeable  to  the  patient.  '  In  order  to  determine  the  extent 
of  improvement  in  the  patient's  condition,  it  is,  of  course,  necessary  to 
make  a  quantitative  analysis  of  the  urine  from  time  to  time. 

When  the  patient's  physical  state  has  improved  satisfactorily,  the  am- 
putation should  be  made  precisely  as  in  senile  gangrene,  but  the  greatest 
speed  should  be  exercised  and  the  slightest  possible  amount  of  traumatism 
inflicted.  There  seems  to  be  no  small  clanger  from  the  late  effects  of  an- 
esthetics in  these  cases,  and  consequently  the  time  of  anesthesia  should  be 
reduced  as  much  as  is  compatible  with  careful  surgical  work. 

The  same  precautions  in  after-treatment  should  be  employed  as  follow- 
ing the  operation  for  senile  gangrene,  but  especial  attention  should  be  given 
to  the  diet  of  these  patients  throughout  the  remainder  of  their  lives. 

$  INGROWN   TOE  NAIL. 

The  suffering  brought  about  by  this  condition  is  very  considerable  and 
out  of  proportion  to  the  simple  character  of  the  lesion.  It  is  usually  the 
result  of  tight  shoes  and  the  trimming  of  the  toe  nail  too  close  at  the  corners. 
When  the  first  pain  is  felt  an  attempt  is  made  to  cut  away  the  edge  of  the 
nail  to  prevent  pressure.  Each  time  the  nail  is  usually  cut  a  little  farther 
back  and  the  condition  gradually  grows  worse.  The  nail  of  the  great  toe 
should  always  be  cut  straight  across. 

In  the  very  mild  cases  relief  may  be  obtained  by  always  cutting  the  nail 
square  across  and  wearing  properly  fitted  shoes. 

Operative  Treatment. 

In  some  of  the  very  pronounced  cases  where  both  edges  of  the  nail  are 
involved,  it  may  be  wise  to  remove  the  entire  toe  nail.  In  the  majority, 
however,  it  is  only  necessary  to  remove  about  one-fourth  of  the  nail.  This 
can  easily  be  done  tinder  local  anesthesia. 

Technique. 

A  small  rubber  drainage  tube  used  as  a  constrictor  is  placed  around 
the  base  of  the  great  toe.  A  solution  of  i  :iooo  cocaine  is  now  injected 
subcutaneous!}-  at  the  base  and  side  of  the  nail  and  underneath  the  nail. 
An  incision  is  then  made  down  through  the  nail  and  its  matrix  parallel  to 
its  long  axis,  on  a  line  so  that  about  one-fourth  of  the  nail  mav  be  removed. 


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SURGERY    OF    THE    EXTREMITIES  877 

(Plate  CLVIII.)  This  one-fourth  of  the  nail,  together  with  its  matrix 
and  the  granulation  tissue  along  the  edge,  is  carefully  dissected  away.  A 
wedge-shaped  piece  of  tissvie  is  removed  at  the  base  and  just  below  the 
lower  end  of  the  nail,  and  the  -defect  closed  with  a  few  horse  hair  stitches. 

A  rather  firm  dry  sterile  dressing  should  be  applied  before  the  rubber 
tourniquet  is  removed". 

The  results  from  this  operation  are  invariably  good. 

BUNION. 

Bunion  is  quite  common  but  is  usually  looked  upon  as  a  very  trivial 
affair,  although  the  discomfort  suffered  by  patients  afflicted  therewith  is 
very  great.  The  condition  is  usually  associated  with  hallux  valgus. 

Among  the  various  causes  the  wearing  of  pointed,  short  and  tight  shoes 
is  the  most  important.  Rheumatic  arthritis  may  be  a  contributing  cause. 
L3atients  with  a  long  great  toe  seem  more  liable  to  develop  a  condition  of 
Iiallux  valgus,  with  the  formation  of  a  bunion,  than  those  with  a  short  great 
toe. 

In  cases  of  well  marked  bunion  there  is  a  true  bony  enlargement  on 
the  inner  side  of  the  head  of  the  metatarsal  bone  of  the  great  toe,  which 
becomes  covered  with  a  bursal  layer. 

Treatment. 

In  cases  where  the  deformity  is  only  slight,  the  wearing  of  properly 
fitted  shoes  will  often  relieve  them,  but  in  the  more  pronounced  forms  an 
operation  is  the  only  method  that  affords  relief. 

Operation. 

During  the  past  few  years  we  have  used  the  method  of  placing  a  flap 
of  the  bursa  down  over  the  end  of  the  resected  metatarsal  bone  after  the 
method  of  C.  H.  Mayo. 

A  curved  incision  with  its  base  downwards  is  made  over  the  inner 
side  of  the  metatarso-phalangeal  joint  and  a  flap  of  skin  is  dissected  loose 
leaving  the  bursa  intact.  A  horse-shoe  shaped  incision  is  then  made  with 
its  base  on  the  phalangeal  side  of  the  joint,  loosening  the  bursa  and  folding 
it  downward,  as  shown  in  Fig.  26.  The  enlarged  head  of  the  meta- 
tarsal bone  is  now  removed  by  using  a  pair  of  heavy  bone-cutting  forceps. T 
Fig.  27  shows  the  bursal  flap  folded  downwards  and  the  metatarsal  bone 
after  its  enlarged  head  has  been  removed.  The  bursal  flap  is  now 
turned  into  the  joint  area  in  front  of  the  cut  end  of  the  bone  and  held  in 
place  by  a  couple  of  cat-gut  stitches  as  shown  in  Fig.  28.  A  small  puncture 
is  made  in  the  base  of  the  skin  flap  for  drainage  and  then  the  skin  is  closed 
by  horsehair  stitches. 

In  applying  the  dressing  a  folded  piece  of  gauze  should  be  placed 
between  the  great  and  second  toes  to  overcome  the  valgus  position  of  the 
great  toe.  The  placing  of  the  bursa  in  the  joint  area  prevents  a  bony  union, 
leaving  a  movable  joint.  The  great  toe  is  shortened  and  the  foot  somewhat 
narrowed  at  its  widest  line. 


PART   XI. 


THE  SURGICAL  HOSPITAL. 

In  order  to  do  surgical  work  successfully,  it  is  necessary  for  the  sur- 
geon to  be  able  to  secure  for  his  patients  proper  hospital  care.  \n  artisan 
doing  his  work  by  going  from  house  to  house  cannot  compete  with  another 
who  does  the  same  class  of  work  in  a  well  equipped  workshop,  and  the  lat- 
ter will  again  do  better  work  in  his  own  shop  than  he  would  in  any  other  in 
which  he  might  execute  one  piece  of  work.  The  surgeon  of  average  ability 
and  experience  will  usually  do  much  better  work  in  his  own  hospital,  with  his 
own  assistant  and  nurses,  than  can  be  done  by  another,  for  instance,  of 
much  greater  skill  in  a  hospital  in  which  neither  the  nurses  nor  the  assistants 
are  thoroughly  familiar  with  his  methods  and  technique.  For  these  leading 
reasons,  and  many  others  which,  however,  refer  more  particularly  to  per- 
sonal comfort,  professional  reputation  and  financial  success,  every  surgeon 
should  have  a  hospital,  or  a  definite  portion  of  a  hospital,  in  \vhich  he  can 
pursue  his  work  systematically  and  after  some  definite  plan  that  is  in  keep- 
ing with  his  technical  ability,  and  which  will  enable  him  to  perform  the  im- 
mediate work  he  has  to  do  in  the  best  possible  way,  and  also  enable  him  to 
make  such  progress  from  year  to  year  as  is  possible  under  the  conditions 
surrounding.  Only  the  progressive  surgeon  can  continue  to  prosper  under 
existing  conditions  of  competition. 

In  planning  a  surgical  hospital,  or  a  surgical  department  of  a  general 
hospital,  it  is  important  to  secure  primarily  the  greatest  possible  facility  for 
caring  for  patients.  Facilities  which  will  give  the  patient  the  best  obtainable 
conditions  for  a  rapid  recovery,  combined  with  the  greatest  possible  comfort 
while  in  the  hospital.  At  the  same  time  it  is  important  to  keep  the  cost  of 
construction  as  low  as  consistent  with  securing  the  above.  In  doing  this, 
however,  it  is  important  always  to  bear  in  mind  that  the  running  expenses 
of  a  hospital  amount  to  as  much  every  three  to  five  years  as  the  original  cost 
of  the  buildings,  hence  it  is  of  the  greatest  importance  to  plan  construction 
so  as  to  insure  economy  in  the  running  expenses  of  the  institution.  In  this 
manner  a  given  amount  of  money  will  readily  produce  much  greater  ad- 
vantage if  the  plans  are  properly  made  than  if  little  or  no  attention  is  given 
to  these  important  features. 

It  should  be  stated  here  that  it  is  always  wise  to  secure  expert  advice 
in  the  construction  of  hospitals.  No  one  would  think  of  employing  an 
oculist  to  remove  a  stone  from  the  ureter,  or  to  make  a  gastro-enterostomy, 
and  still  it  would  be  quite  as  reasonable  to  do  this  as  for  a  surgeon  who  has 
had  no  experience  in  constructing  a  hospital  to  make  his  own  plans,  or  to 
entrust  this  to  an  architect  who  has  never  made  a  special  study  of  hospital 
construction,  but  rather  has  given  his  entire  attention  to  the  building  of 
residences,  stores  or  manufacturing  plants. 


88O  THE    SURGICAL    HOSPITAL 

It  is  advisable  for  the  surgeon  to  make  his  own  outlines,  according  to 
arrangements  he  has  seen  in  other  hospitals,  then  to  have  a  local  architect 
make  preliminary  drawings.  Then  he  should  employ  the  best  available  archi- 
tect who  has  made  a  special  study  of  hospital  construction  and  they  together 
should  thoroughly  revise  such  plans.  Then  the  local  architect  should  care- 
fully complete  these  drawings,  but  before  these  are  turned  over  to  the  build- 
er they  should  again  be  corrected  in  every  detail  by  the  specialist  in  hospital 
architecture.  We  have  repeatedly  seen  this  course  followed  with  the  result  of 
saving  from  twenty  to  fifty  per  cent,  in  cost  of  construction,  an  equal  in- 
crease in  efficiency  and  consequent  reduction  in  cost  of  maintenance  for  the 
entire  time  that  the  hospital  is  in  use  after  its  completion. 

During  the  past  few  years  hundreds  upon  hundreds  of  new  hospitals 
have  been  constructed  in  the  various  American  cities  and  towns,  and  it  is 
an  interesting  fact  that  in  almost  every  instance  these  structures  have  been 
planned  by  people  who  had  previously  given  the  subject  of  hospital  con- 
struction and  location  little  if  any  attention. 

Architecture. 

A  local  committee  usually  employs  a  local  architect  who  consults  the 
essays  on  hospital  construction  prepared  more  than  thirty  years  ago  by  the 
authorities  of  Johns  Hopkins  Hospital.  (Hospital  Construction  and  Organ- 
ization, Baltimore,  1875).  He  may  even  go  so  far  as  to  visit  a  few  of  the 
existing  hospitals  nearby,  chiefly  for  the  inspection  of  apparatus  and  op- 
erating rooms.  He  may  also  get  the  advice  of  one  or  more  physicians  who 
have  never  given  the  slightest  attention  to  hospital  construction,  and  with 
this  preliminary  preparation  the  building  is  planned  and  completed. 

The  result  will  depend  largely  upon  the  special  line  in  which  the  archi- 
tect has  been  active.  If  he  has  been  in  the  habit  of  specializing  in  the  plan- 
ning of  cottages  his  hospital  plans  will  contain  the  characteristics  of  a  cot- 
tage ;  if  he  has  mostly  built  flat  or  apartment  buildings  their  special  features 
will  be  contained  in  the  plans  and  so  on  through  the  entire  list  of  architec- 
tural specialties  from  the  construction  of  grain  elevators  to  churches. 

In  making  an  investigation  concerning  the  construction  of  hospitals  in 
the  U.  S.,  Bertrancl  E.  Taylor  (Brickbuilder,  March,  1904),  found  that  a 
vast  majority  of  all  hospitals  at  the  present  time  were  originally  constructed 
for  some  other  purpose,  old  buildings  having  been  adapted.  He  also  states 
that  the  new  hospitals  have  generally  been  designed  by  architects  of  brilliant 
attainments,  but  who  were  generally  totally  unfamiliar  with  even  the  rudi- 
ments of  hospital  requirements. 

The  excellent  work  of  Henry  G.  Burdett  (Hospitals  and  Asylums  of  the 
World,  London,  1893)  is  sometimes  consulted,  but  this  again  simply  repeats 
the  ideas  which  were  laid  down  in  the  essays  just  mentioned.  The  same  is 
true  if  the  various  German  books  and  pamphlets  are  consulted,  for  in  all  of 
these  practically  the  plan  of  the  Hamburg  Hospital  at  Eppendorf  is  taken 
as  the  best  type,  and  this  was  completed  twenty  years  ago,  and  planned  long 
before  that  time. 

So  thoroughly  have  these  ideas  taken  root  that  in  many  instances  enor- 
mous sums  of  money  have  been  spent  with  the  result  that  all  of  the  patients 
are  compelled  to  exist  near  the  ground,  where  the  air  is  least  wholesome, 
most  thoroughly  laden  with  dampness  of  the  soil  and  with  street  dust. 
Moreover,  the  amount  of  sunlight  is  greatly  interferred  with,  because  so 
large  a  proportion  of  the  available  land  is  either  directly  covered  with 


I 


Fig.  29. 


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Fig.  30. 

Fig.  20.  shows  the  amount  of  space  occupied  by  a  ten-story  building  in  the  middle 
of  a  ten-acre  lot,  extending  from  north  to  south,  so  that  all  the  rooms  have  either  east 
or  west  sunlight  and  the  hall  has  sunlight  from  the  south.  Such  a  building  would 
supply  almost  dustless  air  in  almost  any  location  if  shrubbery  and  trees  were  planted 
along  the  edges  of  the  lot.  It  would  be  much  more  sanitary  than  if  the  same  number 
of  patients  were  housed  in  ten  one-story  buildings,  as  shown  in  Fig.  30,  and  the  cost 
of  construction  and  maintenance  would  be  very  much  less  in  the  former  than  in  the 
latter. 


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Fig.  31. 

The  shaded  lines  show  the  portion  first  constructed. 

If  this  building  is  placed  in  the  position  shown  in  E  or  G,  every  portion  of  every 
outside  wall  will  be  covered  with  sunlight  at  some  time  of  the  day;  if  placed  as  at  F, 
the  entire  north  side  of  the  building  is  not  exposed  to  sunlight  at  any  time  of  day.  It 
is  possible  to  overcome  this  objection  by  placing  the  utilities,  like  elevators,  bath- 
rooms and  service-rooms,  in  this  part  of  the  building  and  leaving  the  remaining  por- 
tions for  rooms  and  wards  for  the  patients. 


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THE    SURGICAL    HOSPITAL 

buildings  or  is  in  the  shadow  of  the  large  number  of  small  buildings  re- 
quired to  house  the  patients. 

We  refer,  of  course,  to  the  plan  of  building  a  large  number  of  one,  or 
one-and  a-half  story  pavilions,  which  has  of  late  become  especially  popular. 

As  an  example  we  may  take  the  new  hospital  for  the  city  of  Vienna. 
That  city  is  notoriously  dusty.  The  authorities  are  constructing  thirty-two 
separate,  low  buildings  which  will  cover  a  great  portion  of  the  available 
ground.  It  will  be  necessary  to  place  some  of  these  buildings  relatively 
near  the  surrounding  streets,  thus  exposing  the  patients  not  only  to  the 
noises  of  the  streets,  but  to  the  dust  which  will  easily  rise  tc  the  height  of 
the  first  story. 

Were  it  contemplated  to  erect  instead  four  wings  of  the  same  size  of 
foundation,  each  eight  stories  high,  it  is  plain  that  the  distance  from  the 
surrounding  streets  could  be  increased  to  such  an  extent  that  by  proper 
planting  of  trees  and  shrubs  the  air  would  be  so  thoroughly  filtered  by  the 
time  it  reached  the  buildings  that  it  would  be  practically  dust  free.  This 
would  be  true  especially  of  the  upper  floors,  but  even  the  first  floor  would 
be  greatly  removed  from  the  dust  and  noise  to  which  a  great  portion  of  all 
the  patients  will  be  exposed  if  the  present  idea  is  carried  out. 

Location. 

The  location  of  hospitals  is  determined  in  the  same  manner.  It  is 
chosen  because  it  is  cheap ;  because  some  philanthropic  person  has  donated 
it  to  the  committee ;  because  some  influential  member  wishes  to  dispose  of  a 
particular  piece  of  property ;  because  it  is  in  the  vicinity  of  some  medical  col- 
lege or  some  selfish  member  of  the  medical  staff  desires  the  hospital  con- 
venient to  his  residence  in  a  large  proportion  of  cases ;  and  only  rarely  be- 
cause it  is  especially  suited  for  a  hospital  site.  In  the  smaller  towns  very 
bad  locations  are  usually  selected  in  all  cases  in  which  the  advice  of  location 
is  left  with  the  physicians,  as  from  lack  of  experience  they  imagine  that  the 
hospital  will  be  more  prosperous  if  located  near  the  business  center  of  the 
town.  They  also  have  the  foolish  idea  that  the  hospital  must  be  within  a  few 
blocks  of  their  offices  or  residences  in  order  that  they  may  readily  be  avail- 
able in  case  of  emergencies,  forgetting  that  emergencies  are  an  unimportant 
factor  and  rarely  occur  during  office  hours. 

There  are  certain  fundamental  principles  which  should  be  borne  in  mind 
in  the  selection  of  a  site  for  a  hospital,  no  matter  whether  it  be  located  in 
a  great  city  or  a  country  town.  Of  course  all  conditions  are  only  relative. 
It  is  but  rarely  possible  to  obtain  the  ideal  in  the  selection  of  a  site,  which 
has  indeed  been  practically  obtained  in  a  few  instances,  of  which  we  men- 
tion that  of  the  Royal  Victoria  Hospital,  in  Montreal,  but  it  is  possible  in 
every  city  or  town  to  approximate  these  conditions  much  more  closely  than 
has  been  done  in  ninety  per  cent,  of  all  hospitals.  It  should  be  stated  here 
that  this  criticism  applies  to  a  much  less  extent,  to  institutions  conducted  by 
sisterhoods  than  any  others,  as  their  selection  of  sites  has  in  many  cases  been 
based  upon  the  following  principles. 

Absence  of  Noise. 

The  site  should  be  in  a  quiet  portion  of  the  city  or  town,  away  from 
noisy  railroad  tracks,  street  cars  or  elevated  railroads,  or  factories.  In 
country  towns  this  may  be  accomplished  easily,  and  in  great  cities  the  loca- 
tion can  be  chosen  at  least  three  blocks  away  from  ordinary  railroad  tracks. 


890  THE    SURGICAL    HOSPITAL 

(Nine-tenths  of  all  of  the  larger  hospitals  of  Chicago  are  located  di- 
rectly upon  one  or  two  street  car  tracks,  or  within  two  blocks  of  an  ordinary 
railroad  track). 

Absence  of  Dust. 

Its  location  should  be  so  chosen  as  to  reduce  exposure  to  street  dust  to 
a  minimum.  This  can  best  be  accomplished  by  selecting  a  high  knoll  in  a 
hilly  town,  or  by  setting  the  building  back  from  the  street  a  considerable 
distance  in  a  flat  city  and  planting  trees  and  shrubs  which  will  act  as  nat- 
ural filters  along  the  edge  of  the  grounds  along  the  streets,  and  by  erecting 
high  buildings.  Very  little  street  dust  relatively,  rises  above  the  second 
story,  so  that  the  higher  stories  are  nearly  free  from  this  contamination.  In 
every  city  there  are  streets  that  are  comparatively  little  used.  This  fact 
should  be  considered  favorably  in  the  selection  of  a  hospital  site. 

Sunlight. 

It  is  so  extremely  simple  to  plan  a  building  so  that  every  room  and  ward 
will  have  sunlight  during  some  portion  of  the  day  that  it  is  surprising  to 
find  many  hospital  buildings  in  which  one-third  or  more  of  the  rooms  never 
have  a  ray  of  sunlight. 

In  order  to  have  sunlight  in  each  room  and  ward  it  is  necessary  only 
to  construct  all  buildings  or  pavilions  from  north  to  south,  which  will  give 
to  one  long  side  sunlight  in  the  morning  and  to  the  other  side  in  the  after- 
noon. 

The  importance  of  sunlight,  its  distribution,  the  production  and  depth 
of  shadows,  together  with  the  bearing  this  subject  has  upon  the  planning 
of  hospitals,  has  been  studied  and  illustrated  with  great  care  by  Wm.  Atkin- 
son, architect,  (Brickbuilder,  July,  1903).  The  various  shapes  of  wings 
have  been  thoroughly  discussed,  with  a  careful  consideration  of  the  amount 
of  sunlight  and  shadow  obtained  by  buildings  of  the  various  forms  usually 
employed.  This  feature  has  received  careful  attention  in  the  work  on  the 
Organization,  Construction  and  Management  of  Hospitals  (Ochsner  and 
Sturm). 

At  this  point  it  may  be  well  to  direct  attention  to  the  fact  that  in  long 
wings  with  a  central  hall,  with  wards  or  rooms  arranged  on  eithef  side  of 
such  hall,  two  outside  and  two  inside  walls  will  house  as  many  patients  as 
four  outside  and  two  inside  walls  would  were  the  wards  or  rooms  arranged 
along  one  outside  wall  and  a  hall  placed  along  the  other  outside  wall,  and 
separated  from  the  wards  or  rooms  by  an  inside  partition.  This  is  plainly 
illustrated  in  Figs  32  and  33,  which  represent  two  typical  plans.  Fig. 
32  shows  a  hospital  extending  from  north  to  south  in  which  every  room  or 
ward  is  exposed  to  sunlight  either  in  the  forenoon  or  afternoon,  and  the  hall 
during  midday.  Fig.  33  represents  a  building  extending  from  east  to  west 
with  all  of  the  rooms  and  wards  exposed  to  the  sun  from  the  south  and 
with  a  hall  extending  along  the  northern  wall. 

It  is  plain  that  the  expense  of  constructing  a  hospital  for  a  given  num- 
ber of  beds  must  be  at  least  sixty  per  cent,  greater  if  plan  No.  33  is  fol- 
lowed than  with  plan  No.  32,  because  the  additional  walls  amount  to  fifty 
per  cent.,  and  there  will  be  required  double  the  amount  of  outside  walls 
which  are,  of  course,  much  more  expensive.  Moreover  the  same  area  of 
hall  space  serves  twice  the  number  of  beds  in  No.  32  that  it  serves  in 
No.  33. 


A    GY.IOCOLOGICAL  £r 


Top  FLOOR  PL  A  i 


OB;>TLTRICAL  HOSPITAL  . 

Fig.  34. 

This  represents  the  top  floor  of  a  very  convenient  small  hospital  extending  north 
and  south.  At  the  north  end  of  the  building  are  located  two  operating  rooms  with 
large  north  windows  and  large  skylights  and  with  an  intervening  sterilizing  room.  If 
the  hospital  is  also  to  accommodate  obstetrical  patients,  the  next  room  on  the  east 
side  may  be  used  for  obstetrical  operations,  otherwise  it  may  be  used  as  a  recovery 
room.  Directly  to  the  north  of  the  elevator  the  hall  is  divided  into  a  north  portion  to 
be  used  in  connection  with  the  surgical  service,  and  a  south  portion  to  be  used  in  con- 
nection with  kitchen  and  dining  rooms.  This  partition  is  not  shown  in  the  figure. 

A  hospital  built  according  to  this  plan  has  been  in  operation  for  several  years  and 
is  eminently  satisfactory. 


R  R      R  L  R    xyJ 

f\       V] 

-  —I     L-  J —  ^A.     ^  ^     L. 


MEYER  J.  STURM    ARCHITECT 


Fig.  35. 
(From    Organization,    Construction,    and    Management    of    Hospitals,    Ochsner    and 

Sturm.) 

Represents  one  floor  of  a  U-shaped  hospital  of  many  stories,  which  combines 
great  convenience,  perfect  arrangement  for  sun  light,  economy  in  conduct,  service, 
heating,  and  lighting.  It  is  an  ideal  plan  for  a  hospital  for  large  cities  in  which 
excellence  of  service  and  economy  in  cost  of  construction,  cost  of  upkeep,  and  cost  of 
maintenance  are  important  elements.  R  represents  rooms,  W  small  private  wards.  K 
rooms  for  eye  patients,  S  service  room.  D  dressing  and  examining  room,  T  toilet,  L 
elevator,  V  veranda.  By  removing  the  partitions  between  two  or  more  of  the  rooms 
R.  wards  may  he  arranged  of  any  desirable  size.  All  rooms  except  those  used  for 
eye  patients  have  sunlight  during  some  part  of  the  day. 


THE    SURGICAL    HOSPITAL  895 

But  this  is  not  all ;  the  distance  of  travel  required  by  those  employed  in 
caring  for  the  sick  is  just  doubled.  The  area  of  the  hall  which  must  be  kept 
clean  is  twice  as  great.  The  number  of  windows  which  must  be  kept  clean 
is  approximately  twice  as  great. 

Aside  from  this  there  is  the  disadvantage  in  plan  33  from  the  fact 
that  twice  the  surface  of  outside  wall  is  exposed  to  the  weather  and  twice 
the  amount  of  hall  space  must  be  heated. 

Against  this  we  have  the  fact  that  in  plan  33  every  room  is  exposed 
to  the  south.  In  most  climates  it  is  likely  that  exposure  to  sunlight  for  half 
the  day  is  equally  satisfactory  in  all  except  the  summer  season,  and  to  be 
preferred  in  this  season. 

It  seems  plain  consequently  that  plan  No.  32  is  much  to  be  preferred. 

Freedom  from  Smoke. 

In  many  of  our  great  cities  there  are  locations  in  which  there  is  but 
rarely  any  sunshine  because  of  the  presence  of  coal  smoke  from  large  fur- 
naces and  factories.  These  locations  should  of  course  be  avoided  in  select- 
ing hospital  sites. 

It  is  well  to  note  the  general  direction  of  winds  and  to  bear  in  mind  the 
fact  that  smoke,  although  very  diffusible  in  the  air,  will  not  be  distributed 
to  any  considerable  extent  against  even  the  slightest  current  in  the  air.  It 
is  also  important  to  bear  in  mind  that  when  the  air  is  apparently  still  it 
nevertheless  travels  at  a  rate  of  about  one  hundred  feet  per  minute,  or 
about  as  one  would  move  in  sauntering  along  the  street,  taking  a  step  in  two 
seconds. 

Again,  in  protecting  the  institution  against  smoke  from  any  given  source 
one  may  obtain  a  fair  idea  of  the  entire  amount  that  will  be  delivered  to  an 
institution  in  still  air  by  taking  the  distance  from  that  source  as  the  radius  of 
a  circle  of  which  the  segment  corresponding  to  the  length  of  the  institution 
indicates  the  relative  proportion  of  the  smoke  carried  to  this  distance  which 
will  be  delivered  to  the  institution. 

This  illustration  is  employed  to  show  how  little  of  the  entire  volume  of 
smoke  will  be  delivered  to  any  given  space  which  may  be  occupied  by  the 
hospital  in  still  air,  and  if  the  location  is  wisely  chosen  with  this  point  in 
view  it  is  usually  possible  to  have  the  hospital  on  the  windward  side  of  the 
sources  of  especially  great  smoke  producers  during  the  prevailing  winds, 
and  thus  the  smoke  nuisance  will  not  be  so  much  of  an  annoyance  as  one 
might  expect.  Fortunately  smoke  is  usually  produced  in  certain  centers  so 
that  one  may  practicallv  avoid  them  to  a  very  considerable  extent,  by  the 
careful  selection  of  the  site. 

Accessibility. 

Without  disregarding  the  principles  already  mentioned  it  is  important 
that  hospitals  should  be  accessible  to  patients,  to  their  friends,  and  to  the 
officers  of  the  hospital  staff.  This  is  importnnt  because  it  is  not  well  for 
many  acute  cases,  such  as  pneumonia,  tvohoid  fever,  peritonitis,  etc.,  to  be 
transported  a  great  distance.  Since  the  introduction  of  properlv  con- 
structed ambulances  in  which  the  stretchers  are  suspended  from  the  roof 
upon  spiral  springs,  and  in  which  the  wheels  are  provided  with  rubber  tires, 
the  objection  to  transportation  for  a  distance  of  several  miles  has  verv 
little  real  weight,  provided  the  ambulance  service  is  properly  organized. 
With  modern  automobile  ambulances  a  distance  of  ten  miles  is  really  of  no 
importance  if  the  roads  are  good.  Tn  large  cities  ambulances  should  be  built 


896  THE    SURGICAL    HOSPITAL 

so  that  the  wheels  can  run  on  street  car  rails  which  will  make  the  selection 
of  smooth  roads  always  possible. 

Great  distances  are  a  hardship  to  the  friends  of  patients  who  belong 
to  the  working  classes,  because  of  the  time  and  expense  involved  in  visiting 
such  hospitals,  and  although  it  is  usually  better  for  the  patient  if  his  visitors 
are  few,  still  the  fact  that  it  is  difficult  for  friends  to  reach  a  distant  hospital 
frequently  serves  as  a  sufficient  ground  for  them  to  prevent  patients  who 
could  be  best  treated  in  a  hospital  from  availing  themselves  of  this  blessing. 

Great  distance  also  often  prevents  physicians  and  surgeons  of  the  great- 
est learning  and  skill  from  serving  upon  a  hospital  staff,  as  the  time  spent  in 
going  to  and  from  the  hospital  seems  too  great  in  proportion  to  the  time 
spent  in  actual  work  therein.  But  since  the  adoption  of  automobiles  has  be- 
come so  general,  this  objection  no  longer  requires  consideration,  except  in 
very  cold  climates  where  their  use  is  not  profitable  during  the  winter  months. 

Hospitals  should  be  located  in  residence  districts  of  cities  and  towns,  as 
the  same  conditions  which  make  a  location  desirable  for  residence  make  it 
favorable  for  a  hospital.  The  nearer  such  a  site  is  to  a  park,  a  lake,  the 
high  banks  of  a  river,  or  the  seashore,  the  better. 

Size  of  Grounds. 

It  is  of  the  greatest  importance  to  have  a  good-sized  area  of  land,  as  this 
will  prevent  the  contamination  of  the  air  by  immediate  neighbors.  It  will 
make  a  free  sweep  of  air  possible.  The  buildings  can  be  set  back  on  the 
grounds  so  as  to  sufficiently  secure  some  of  the  conditions  mentioned  above. 

A  hospital  should  never  be  placed  between  a  number  of  large  build- 
ings in  the  middle  of  a  block — a  position  too  frequently  chosen  at  the  pres- 
ent time. 

Even  in  the  smaller  villages  one  frequently  finds  hospitals  almost  com- 
pletely filling  the  grounds.    It  is  practically  always  possible  to  secure  at  least 
five  acres  of  land  for  hospital  grounds,  as  in  most  communities  this  land  is 
not  subject  to  taxation,  and  it  is  always  a  good  investment. 
Buildings. 

Having  chosen  a  suitable  location  the  question  of  planning  the  build- 
ings themselves  must  be  considered. 

Forty  years  ago  the  theory  of  isolation  of  all  portions  of  hospitals  from 
all  other  portions,  received  special  favor  owing  to  the  views  then  held  re- 
garding contamination  and  infection.  It  was  supposed  that  an  ideal  con- 
dition would  be  established  if  each  patient  could  occupy  a  separate  building 
supplied  with  all  conveniences. 

As  this  was  not  practicable  it  resulted  in  the  planning  of  hospitals  com- 
posed of  numerous  small  separate  buildings,  usually  one  or  two  stories  in 
height.  There  developed  a  fear  of  scattering  disease  from  one  patient  to 
another  through  the  medium  of  air  contamination.  Singularly  enough  this 
view  was  due  to  the  fact  that  the  real  cause  of  contagion  had  not  as  yet  been 
established  and  it  was  simply  known  that  some  diseases  were  transmissible 
from  patient  to  patient.  It  was  not  then  known  that  definite  organisms  must 
be  carried  from  one  patient  to  the  other  in  order  to  cause  this  transmission 
of  certain  diseases.  It  is  plain  that  if  those  who  cared  for  patients  in  one 
pavilion  could  not  come  in  contact  with  patients  in  another  pavilion,  the  lat- 
ter would  not  be  infected  from  the  former. 

In  this  manner  a  practical  solution  was  found,  although  this  had  not 
been  ba^ed  upon  a  scientific  knowledge  of  existing  facts. 


'JECU1D  Tl.OOR  Pi.  VI 

A   COU/ITPY  HOSPITAL 


Fig.  36. 

(By  courtesy  of  M.  J.  Sturm,  hospital  architect.) 

We  have  here  a  small  hospital  for  a  small  country  town.  The  building  extends 
north  and  south,  and  thus  supplies  sunlight  for  all  rooms  and  for  the  hall,  which  must 
have  large  glass  doors  at  each  end.  The  building  may  be  built  one,  two,  or  three 
stories  high.  It  has  all  facilities  of  the  modern  city  hospital. 


Fig.  37. 

This  shows  the  arrangement  of  buildings  for  a  large  hospital  in  a  city  of  con- 
siderable size. 

B  B  represents  separate  pavilions  extending  from  north  to  south,  one  for  men,  the 
other  for  women.  They  may  be  constructed  in  any  desirable  length  and  of  as  many 
stories  as  may  be  wanted.  A  represents  the  central  administration  building,  C  the 
operating  pavilion,  D  the  home  for  servants,  and  E  the  home  for  nurses.  The  base- 
ment of  the  operating  department  may  be  used  for  boiler  and  engine  room  on  one  side 
and  laundry  on  the  other.  The  first  floor  may  be  used  for  dispensary,  or  the  laundry 
may  be  placed  on  the  ground  floor  of  the  servants'  building,  D. 


THE    SURGICAL    HOSPITAL  9OI 

Although  we  knpw  that  there  is  a  definite  difference  between  diseases 
transmitted  from  patient  to  patient,  and  the  very  much  larger  class  in  which 
this  is  not  possible,  the  fundamental  idea  underlying  all  hospital  construc- 
tion still  centers  about  this  theory  of  air  contamination. 

In  reviewing  recent  literature  on  hospital  construction  one  constantly 
finds  a  reiteration  of  this  idea.  The  various  authors  seem  to  be  impressed 
with  the  danger  of  the  communication  of  disease  from  one  patient  to  an- 
other, even  in  non-contagious  and  non-infectious  diseases,  and  this  is  an  idea 
expressed  not  only  by  architects  whose  ignorance  in  this  direction  would  be 
excusable,  but  also  by  members  of  the  medical  profession.  And  yet  when 
one  asks  hospital  physicians  of  large  experience  for  an  example  of  such  an 
occurrence  among  the  thousands  of  cases  observed  one  finds  that  no  such 
instances  have  happened  in  the  actual  experience  of  those  with  vast  practice. 

The  knowledge  of  this  fact  should  make  it  plain  that  there  should  in 
the  first  place  be  a  definite  isolation  of  all  cases  whose  disease  can  be  trans- 
mitted by  contact  or  by  infection,  and  on  the  other  hand  that  the  other  cases 
should  be  placed  in  buildings  constructed  with  a  view  to  securing  conditions 
favorable  to  the  treatment  of  the  diseases  involved,  and  not  with  a  view  of 
securing  a  degree  of  isolation  which  in  this  very  large  class  is  of  absolutely 
no  value,  but  of  very  great  inconvenience  and  expense. 

These  patients  need  an  abundance  of  clean  air,  sunlight,  proper  food 
and  excellent  nursing  in  clean  rooms,  properly  heated,  and  as  little  disturbed 
by  noises  as  possible.  They  should  also  be  protected  against  danger  from 
fire. 

All  of  these  requirements  should  be  secured  at  as  slight  an  expense  as 
possible,  as  all  available  funds  can  always  be  employed  with  benefit  even 
though  no  money  be  expended  unnecessarily.  The  follies  which  have  been 
committed  in  the  way  of  obtaining  a  very  slight  amount  of  benefit  to  the 
patients  for  the  amount  of  money  expended  are  extraordinary. 

It  is  necessary  to  study  the  expense,  ist,  from  the  standpoint  of  primary 
cost  of  construction,  and  2nd,  from  the  standpoint  of  cost  of  maintenance. 

In  constructing  buildings  to  house  a  given  number  of  patients  the 
first  and  the  last  stories  are  always  of  the  greatest  expense,  as  the  first  story 
implies  the  cost  of  a  foundation  with  its  system  of  drains  for  the  proper 
disposition  of  the  sewerage.  The  last  story  is  again  expensive  because  of 
the  necessity  of  covering  it  with  a  suitable  roof. 

These  items  may  be  divided  into  units  of  cost  where  the  foundation 
proper  (footings)  are  taken  as  one,  the  cellar  or  foundation  walls  as  one 
and  the  first  story  as  one,  the  superstructure  (roof,  walls,  etc.)  as  one.  This 
makes  a  total  of  four  units  for  the  first  story  covered,  or  for  a  one  story 
building.  Each  additional  story  between  the  first  three  and  the  last  is  an 
added  unit,  so  that  in  a  six  story  building  we  have  the  original  four  plus  the 
five  added  stories,  making  nine  as  against  twenty-four  units  for  six  pavilions 
of  the  same  area.  This  will  be  found  to  be  a  fair  proportion. 

The  intermediate  stories  require  no  foundation,  the  same  sewer  system 
which  serves  the  first  story  can  be  made  to  serve  all  of  the  succeeding  sto- 
ries, and  the  roof  covering  the  last  story  will  serve  all  the  intervening  ones. 
The  only  difference  lies  in  the  strength  of  the  foundation  and  the  thick- 
ness of  the  walls,  which  must  be  proportionate  to  the  height  of  the  building. 

It  is  also  absolutely  necessary  that  a  high  building  be  supplied  with  an 
elevator,  and  that  its  construction  be  thoroughly  fire-proof,  both  conditions 
not  required  in  a  one-story  building.  Rut  nevertheless  the  cost  of  construe- 


9/O2  THE    SURGICAL    HOSPITAL 

tion  of  one  of  these  high  buildings  is  much  less  in  proportion  to  the  num- 
ber of  patients  housed  than  that  of  one-story  buildings. 

It  will  readily  be  seen  that  the  primary  cost  and  maintenance  of  the 
plant  will  be  greater  in  one  story  pavilion  hospitals  than  in  superimposed 
stories,  as  in  the  latter  the  system  is  simpler  in  construction,  more  direct 
and  so  more  economical  in  all  ways.  This  holds  especially  also  for  the 
plumbing,  as  the  superimposed  bath-rooms,  etc.,  need  but  one  stack  and 
vent  for  each  separate  tier  and  can  be  run  more  advantageously.  Again 
in  the  heating  of  these  buildings  the  amount  of  heat  wasted  in  cold  weather  is 
much  greater  in  one  story  buildings  because  of  the  relatively  greater  amount 
of  surface  exposed  to  the  outer  air. 

The  difference  in  cost  of  construction  between  fireproof  and  non-fire- 
proof is  decreasing  constantly,  especially  so  since  many  of  the  new  so- 
called  "armored  concrete"  constructions  have  been  brought  forward.  Some 
of  these  are  the  equal  of  any  construction  known  and  cost  but  little  if  any 
more  than  first-class  frame  construction  in  larger  buildings.  This  is  more 
evident  since  wood  has  become  scarce  and  correspondingly  costly  in  the  last 
few  years.  This  is  of  very  great  importance  as  it  makes  it  possible  to  ob- 
tain the  advantages  of  housing  the  patients  in  a  high  building  away  from 
the  noise  and  dust  of  the  streets  and  the  dampness  of  the  soil,  without  ex- 
posing them  to  the  dangers  from  fire  and  without  increasing  the  cost  of 
construction  to  an  unreasonable  amount. 

The  use  of  the  modern  elevator  and  the  automatic  dumb-waiter  makes 
it  possible  to  care  for  patients  in  a  building  of  a  number  of  stories  at  a  much 
smaller  expense  than  when  housed  in  a  number  of  separate  cottages. 

There  is  one  great  danger  in  the  adoption  of  high  buildings  for  hos- 
pitals in  the  fact  that  there  is  a  great  temptation  to  decrease  the  area  of  the 
land  upon  which  the  hospital  is  built,  while  increasing  the  height  of  the 
building.  This  would,  of  course,  be  a  fatal  error  as  it  would  destroy  the  ad- 
vantages to  be  gained  from  high  buildings,  especially  if  the  neighboring 
buildings  were  also  high. 

The  nearest  building  should  be  twice  the  distance  of  its  height  away 
from  the  hospital  in  order  that  there  be  no  serious  interference  with  sun- 
light and  with  the  air  supply.  It  is  important  in  designing  hospitals  to  ar- 
range a  flat  roof  properly  planned  to  serve  for  an  out-door  sleeping  pavilion. 
In  this  way  the  best  possible  facilities  can  be  obtained  for  patients  to  recover 
from  anesthesia  after  operations  and  for  the  care  of  other  patients  who  are 
best  off  in  the  open  air.  Of  course,  the  elevator  and  all  other  utilities  must 
be  provided. 
Shape  of  the  Building — Ground  Plan. 

Much  attention  has  been  given  to  the  perfection  of  ideal  ground-plans 
for  hospital  buildings.  William  Atkinson  states  the  principles  to  be  ob- 
served in  the  following  concise  manner :  "First.  To  secure  a  large  amount 
of  sunlight  for  each  building.  Second.  To  impede  as  little  as  possible  the 
circulation  of  air  in  and  about  the  building.  Third.  To  provide  for  the  future 
enlargement  of  the  hospital.  Fourth.  To  promote  convenience  and  econ- 
omy of  administration." 

It  is  plain,  that  with  a  building  a  number  of  stories  high,  all  of  these 
fundamental  principles  may  be  solved  in  the  simplest  possible  manner. 

First.  A  building  constructed  on  the  general  plan  indicated  in  Fi>. 
32  furnishes  a  large  amount  of  sunlight  for  every  room  or  ward,  as  well 


THE    SURGICAL    HOSPITAL  905 

as  for  the  hall.  It  is  important,  however,  that  the  hall  extend  the  entire 
length  of  the  building-  and  that  it  be  not  obstructed  by  end- rooms  or  project- 
ing walls  at  any  point  in  its  extent.  It  is  best  to  construct  the  end  of  the 
hall  almost  entirely  of  windows  and  large  glass  doors  by  means  of  which 
patients  can  be  wheeled  onto  the  porches. 

Second.  The  higher  the  building  the  less  will  be  the  obstruction  to  the 
air. 

Third.  Future  enlargement  may  be  accomplished  by  adding  more  sto- 
ries, provided  the  foundation  is  built  sufficiently  heavy  to  permit  this. 

Fourth.  Being  compact  it  must  be  convenient  and  economical  to  man- 
age. 

The  same  author  gives  a  sun  plan  of  the  various  typical  forms  which 
may  be  given  to  a  ground  plan,  illustrating  with  excellent  diagrams  the 
amount  of  sunlight  as  well  as  the  extent  and  the  depth  of  shadows  pro- 
duced by  each  form. 

A  study  of  these  diagrams  will  convince  any  one  that  the  form  indicated 
in  Figs.  34  and  35  contains  the  greatest  number  of  advantages.  This  plan  can 
be  carried  out  by  simply  building  a  single  pavilion  as  shown  in  Fig.  34  or 
two  or  more  of  these  pavilions  may  be  built  in  a  row  with  a  sufficient  space 
between. 

These  plans  may  all  be  united  by  a  one  story  corridor,  or  building,  which 
should  preferably  be  placed  at  the  north  of  the  pavilions  in  order  not  to 
throw  a  shadow  upon  the  land  between  the  various  pavilions.  In  this  way 
another  means  of  enlarging  the  institution  by  adding  further  pavilions  may 
be  provided. 

Or  they  may  be  placed  in  the  form  shown  in  Fig.  35  with  the  open 
court  facing  south,  or  better  still,  a  little  east  or  west  of  south.  Fig.  36 
gives  a  plan  for  a  small  country  hospital  which  represents  the  same  principle. 
This  building  must  of  course  also  extend  from  north  to  south. 

In  large  institutions  for  the  care  of  the  sick  in  great  cities  it  is  well  to 
consider  a  ground  plan,  as  shown  in  Fig.  37,  in  which  one  wing  or  tier 
of  pavilions  is  intended  for  male,  the  other  for  female,  patients,  the  admin- 
istration building  being  placed  between  these  two  wings  at  an  equal  dis- 
tance from  each. 

Aside  from  providing  for  the  housing  of  the  patients  it-  is  necessary  to 
make  provision  for  the  housing  of  the  officers  of  the  institution,  the  resident 
medical  staff,  the  nurses  and  the  servants.  Provision  must  also  be  made 
for  the  administrative  offices,  for  the  kitchen,  laundry  and  boilers  supplying 
heat  and  steam  power. 

If  but  a  single,  many-storied  building  is  chosen  it  is  well  to  place  the 
offices  in  the  first  floor,  as  well  as  the  rooms  for  the  house  staff,  the  drug 
room,  laboratories  and  the  examining  rooms,  as  this  places  the  patients  in 
the  higher  stories  where  they  are  away  from  the  disturbances  naturally  oc- 
curring on  the  first  floor. 

It  is  usually  better  to  house  the  servants  and  nurses  in  a  separate 
building,  so  as  to  compel  them  to  be  away  from  the  hospital  proper  during 
their  time  of  rest. 

It  is,  however,  often  more  convenient  to  build  the  original  hospital 
building  sufficiently  large  to  house  the  patients  as  well  as  the  servants  and 
nurses  at  first,  and  as  the  latter  space  is  required  for  patients,  to  then  pre- 
pare separate  quarters  for  the  nurses  and  servants. 


9/O6  THE    SURGICAL    HOSPITAL 

Kitchen. 

In  such  a  building  the  kitchen  should  be  in  the  top  story,  connected  with 
all  the  stories  by  means  of  a  dumb-waiter,  each  story  having  besides  its 
own  diet  kitchen  and  nurses  room.  This  prevents  the  annoyance  which 
invariably  exists  from  the  odors  of  cooking  when  the  kitchen  is  in  any  other 
portion  of  the  building. 

Operating  Rooms. 

The  operating  rooms  should  also  be  in  the  uppermost  story  in  order  to 
secure  the  air  freest  from  dust  and  to  prevent  annoyance  of  the  other  pa- 
tients during  operations,  and  so  the  principal  light  for  operating  may  be 
obtained  through  north  skylights. 

Recovery    Rooms. 

It  is  well  to  provide  a  number  of  rooms  in  this  story  in  which  patients 
may  be  kept  twenty-four  hours,  or  longer,  after  the  operations,  so  as  to  pre- 
vent the  disturbance  of  other  patients  in  the  hospital  by  those  who  have 
just  been  operated. 

In  this  manner  all  of  the  business  of  the  hospital  at  all  likely  to  disturb 
patients  is  conducted  in  the  first  and  last  stories  of  the  building,  as  far  as 
possible  away  from  the  inmates. 

Heating. 

The  problem  of  heating  depends  largely  upon  the  climate  in  which  the 
hospital  is  located.  In  most  cities  in  this  country  it  is  necessary  to  provide 
efficient  means  of  heating  hospitals  during  the  cold  season  of  the  year. 

The  most  economical  form  of  heating  in  the  colder  portions  of  this 
country  is  by  direct  radiation  from  steam  coils,  in  the  warmer  portions  of 
the  country  from  hot  water  coils. 

There  is  no  doubt  but  that  air  which  has  come  directly  in  contact  with 
steam  coils  heated  to  212°  F.  is  not  nearly  as  wholesome  as  that  which 
has  not  been  exposed  to  so  high  a  degree  of  heat.  With  the  ordinary  steam 
coil  there  is,  however,  only  a  small  proportion  of  the  air  contained  in  a 
room  which  comes  directly  in  contact  with  the  coils.  The  greater  portion  of 
the  entire  amount  of  the  air  in  a  room  being  heated  by  contact  with  air 
nearer  the  coil  which  has  been  heated,  consequently  only  a  portion  of  the 
air  is  spoiled  by  being  overheated  by  this  system. 

All  systems  of  combined  heating  and  ventilation  by  means  of  indirect 
heat  with  forced  ventilation  are  extremely  expensive  and  very  unsatisfac- 
tory and  should  be  absolutely  condemned  in  hospital  construction. 

Ventilation. 

The  question  of  ventilation  is  usually  discussed  in  connection  with  heat- 
ing, because  in  cold  weather  the  fresh  air  brought  into  a  room  must  first 
be  heated  in  some  manner  before  being  delivered  to  the  patient. 

In  natural  ventilation,  which  occurs  through  the  walls  of  the  buildings, 
or  through  cracks  about  the  doors  and  windows,  the  cold  air  entering  is 
heated  by  coming  in  contact  with  the  air  already  in  the  room. 

Artificial  Ventilation. 

In  artificial  ventilation  there  are  still  many  practical  problems  which 
have  not  been  definitely  settled. 

This  kind  of  ventilation  may  be  accomplished  by  removing  the  air  in  the 


THE    SURGICAL    HOSPITAL  907 

room  by  means  of  fans,  or  through  heated  flues  in  which  a  draft  is  caused 
by  the  fact  that  hot  air  rises,  becauses  of  its  decrease  in  weight,  due  to 
expansion. 

The  space  occupied  by  the  air  removed  from  a  room  by  either  of 
these  methods  will  be  filled  with  air  coming  from  without,  either  through 
openings  provided  at  points  at  which  the  cold  air  has  to  pass  over  heated 
radiators,  or  through  a  main  duct  above  the  roof,  and  necessary  heating 
coils  below  the  same  to  a  settling  chamber,  and  then  by  smaller  ducts  to 
the  various  rooms. 

Another  method  consists  in  forcing  air  by  the  use  of  fans  through  a 
chamber  heated  by  coils,  thence  through  flues  into  the  various  rooms  and 
wards.  This  plan  may  be  employed  alone  or  in  combination  with  the 
methods  just  mentioned,  by  means  of  which  the  bad  air  is  drawn  out  of  the 
rooms.  But  this  method  has  among  its  leading  drawbacks  this,  that  a  con- 
stant temperature  cannot  be  maintained,  owing  to  external  and  internal 
variations  and  conditions. 

(There  are  always  air  spaces  which  contain  air  which  can  be  displaced 
only  with  difficulty,  while  there  are  other  spaces  in  which  the  air  can  be 
changed  easily,  consequently  the  fresh  air  will  constantly  be  forced  into 
spaces  which  are  least  in  need  of  a  change,  while  other  portions  of  the  room 
will  continue  to  contain  vitiated  air). 

If  this  plan  is  chosen,  it  is  important  to  take  the  air  from  a  high 
point  and  never  from  the  level  of  the  ground,  because  in  this  manner  air 
relatively  free  from  dust  and  moisture  of  the  soil  may  be  obtained. 

It  is,  however,  important  that  the  intake  be  at  a  point  where  the  air  is 
not  vitiated  by  the  bad  air  forced  out  of  the  building,  or  by  smoke  from  the 
chimneys,  or  sewer  gas  from  the  soil  pipes  which  project  beyond  the  roof. 
This  may  be  accomplished  by  placing  the  intake  to  the  windward  side  of  the 
building  during  the  cold  season  of  the  year,  for  it  is  during  such  season  that 
the  forced  ventilation  will  be  in  use. 

The  heat  chamber  through  which  the  air  is  forced  should  be  supplied 
with  hot  water  pipes  in  which  the  heat  is  regulated  so  as  not  to  exceed 
160°  F.,  as  air  blown  over  pipes  heated  with  steam  to  212°  F.,  loses  much 
of  the  invigorating  effect  obtainable  from  fresh  air. 

Theoretically  it  has  seemed  that  a  system  which  combines  the  plan 
of  withdrawing  the  vitiated  air  from  the  rooms  by  means  of  a  system  of 
tubes,  and  fans  which  force  into  the  rooms  at  the  same  time  a  sufficient 
amount  of  air  taken  from  a  point  at  which  it  is  most  likely  to  be  pure,  would 
result  in  the  best  possible  conditions. 

In  many  buildings,  not  only  all  of  the  air,  but  all  of  the  heat  has  been 
supplied  in  this  manner,  the  air  being  heated  sufficiently  in  passing  over  the 
coils  in  the  hot  air  chamber  to  supply  the  necessary  heat. 

The  great  advantage  in  this  system  comes  from  the  fact  that  in  order 
to  secure  a  sufficient  amount  of  heat  a  great  amount  of  fresh  air  will  have 
to  be  supplied,  and  in  this  manner  the  ventilation  must  necessarily  be  ex- 
cellent during  the  cold  season.  The  amount  of  heat  supplied  to  each  room 
can  be  automatically  determined. 

There  are  four  important  objections  to  this  system,  i.  The  principal 
reason  for  rejecting  this  method  lies  in  the  fact  that  very  large  ducts  and 
outlet  surfaces  must  be  provided,  a  condition  of  things  which  is  practically 
almost  impossible  in  the  economic  arrangements  of  a  hospital.  Smaller 


908  THE    SURGICAL    HOSPITAL 

ducts  and  outlets  would  not  be  practicable  owing  to  the  velocity  of  the  in- 
gress and  egress  of  air  necessary  to  give  both  heat  and  air  sufficient  to  do  the 
work.  2.  The  expense  of  maintaining  it  is  very  great.  3.  If  the  coils  are 
heated  by  steam  the  air  loses  much  of  its  invigorating  effect  because  a  great 
portion  is  actually  overheated.  4.  In  autumn  and  spring  it  is  almost  im- 
possible to  supply  a  sufficient  amount  of  air  to  each  room  without  overheat- 
ing it  unless  hot  water  coils  are  used  which  are  regulated  so  that  their 
temperature  does  not  exceed  120°  F.  during  the  autumn  and  spring,  while 
later  it  is  raised  to  160°  F.,  and  as  the  air  passes  over  the  coils  more  slowly 
a  greater  relative  proportion  of  it  comes  in  direct  contact  with  the  coils 
and  is  consequently  more  thoroughly  spoiled  than  in  winter.  Moreover,  in 
winter  when  large  quantities  of  cold  air  are  blown  over  the  coils  the  sur- 
face of  the  latter  never  quite  reaches  the  temperature  of  the  steam  con- 
tained within,  and  this  in  turn  prevents  the  air  from  being  spoiled  by  over- 
heating. 

Whether  it  would  be  possible  to  supply  a  sufficient  amount  of  heat  in 
very  cold  weather  if  the  hot  air  chamber  were  heated  by  hot  water  coils  at 
a  temperature  not  to  exceed  160°  F.  we  cannot  state  because  so  far  as  we 
have  been  able  to  learn  this  plan  has  not  as  yet  received  a  practical  test. 
That  this  would  greatly  improve  the  quality  of  the  warm  air  there  can  be 
no  doubt. 

It  would  consequently  seem  best  to  supply  only  the  fresh  air  for  ventila- 
tion heated  in  such  a  chamber  while  the  heat  for  heating  the  building  would 
be  supplied  by  direct  radiation. 

This  would  at  once  be  economically  and  hygienically  correct.  In  the 
spring  and  autumn  when  only  a  very  small  amount  of  heat  is  required  it 
would  not  be  necessary  to  use  the  steam  radiators  as  a  sufficient  amount  of 
heat  could  be  supplied  with  the  ventilation. 

In  buildings  in  which  the  air  passes  over  coils  heated  with  steam  the 
atmosphere  is  most  depressing  during  the  months  when  little  heat  is  required, 
as  the  volume  of  fresh  air  forced  into  the  rooms  is  smaller  than  during  the 
coldest  season,  hence  a  greater  portion  comes  in  contact  with  the  over- 
heated coils,  and  the  surface  of  these  coils  is  of  a  higher  temperature  than 
when  a  large  amount  of  cold  air  is  forced  over  the  coils,  hence  there  is  not 
only  less  air,  but  the  air  is  of  a  poorer  quality. 

During  the  warm  season  of  the  year  when  no  artificial  heat  is  required, 
open  windows  and  straight  corridors  are  of  the  greatest  importance,  as  well 
as  careful  grouping  whenever  several  buildings  are  constructed,  to  prevent 
obstruction  to  currents  of  air. 

In  this  again  the  higher  the  building  the  freer  will  be  the  currents  of 
air,  because  of  the  fact  that  there  must  necessarily  be  less  obstruction  from 
surrounding  structures  and  hence  the  natural  ventilation  must  be  better. 

Filtering  of  Air. 

The  best  methods  of  cleansing  air  are  the  natural  ones.  Air  which  has 
been  carried  across  a  large  body  of  water  is  practically  free  from  impurities, 
because  these  have  fallen  into  the  water.  Air  near  the  tops  of  high  moun- 
tains is  pure  because  impurities  fall  to  the  ground  before  they  are  carried  to 
these  great  heights.  In  tall  buildings  there  are  more  micro-organisms  in 
the  air  entering  from  without  in  the  lower  than  in  the  upper  floors. 

For  these  reasons  it  seems  wise  to  obtain  as  large  a  piece  of  land  as  the 
means  will  permit,  on  the  highest  available  piece  of  ground,  and  then  put  the 


THE    SURGICAL    HOSPITAL 


909 


buildings  as  near  the  center  of  such  area  as  possible.  The  higher  the  build- 
ings, the  better  will  be  the  chances  of  obtaining  good  air  for  the  greatest 
number  of  patients. 

Shrubs  and  trees  planted  between  the  building  and  the  surrounding 
streets  will  serve  to  filter  a  considerable  portion  of  the  street  dust  out  of 
the  air  before  it  reaches  the  building. 

In  forcing  air  into  a  building  for  the  purpose  of  ventilation  it  is  pos- 
sible to  select  that  which  is  relatively  free  from  dust  and  impurities  if  the 
intake  has  its  opening  at  a  good  height  somewhere  near  the  roof  of  the 
building,  but  in  such  a  position  that  the  prevailing  winds  will  force  the  im- 
purities which  come  from  the  chimneys  and  ventpipes  away  from  the  intake. 

Many  devices  have  been  instituted  for  the  purpose  of  washing  the  air 
which  is  forced  into  a  building  by  fans.  Streams  of  water  are  permitted  to 
drip  over  moist  gauze  or  other  substances  so  as  to  intercept  the  fine  particles 
contained  in  the  air.  This  treatment  of  the  air  has,  however,  not  yet  been 
fully  and  satisfactorily  demonstrated,  although  many  authorities  speak 
well  of  it. 

A  method  which  has  been  used  frequently  by  the  government  in 
some  of  its  hospitals,  and  especially  in  its  larger  office  buildings,  is  to  heat  the 
air  above  freezing  point  and  then  pass  it  through  a  wall  of  finely  sprayed 
water,  there  being  many  of  these  small  apartments  about  eighteen  inches 
square  so  as  to  keep  the  water  from  spreading.  This  is  economical  as  the 
water  can  be  filtered  and  used  over  and  over.  The  air  is  then  sent  into  a 
drying  room  and  from  there  into  a  space  where  a  fine  spray  gives  it  the 
requisite  moisture,  the  drying  room  being  kept  at  a  temperature  so  that  the 
air  goes  out  to  the  several  ducts  at  slightly  higher  temperature  than  that 
of  the  rooms.  The  system  has  been  found  very  satisfactory,  exceedingly 
simple  and  inexpensive. 

Lighting. 

Incandescent  electric  lights  are  probably  the  most  cleanly,  convenient 
and  satisfactory  in  most  cities.  In  large  institutions  requiring  high  pressure 
steam  for  other  purposes,  such  as  running  elevators,  pumps,  laundry  ma- 
chinery, etc.,  electricity  can  be  manufactured  at  a  reasonable  expense  for 
lighting  the  building. 

If  the  institution  is  dependent  upon  ordinary  illuminating  gas  it  is  pref- 
erable to  make  use  of  some  one  of  the  various  incandescent  mantles  in  the 
market,  as  the  quality  of  the  light  is  thus  greatly  improved,  while  for  the 
same  amount  of  light  the  amount  of  carbon  dioxide  and  smoke  are  greatly 
reduced  in  quantity,  moreover  it  is  much  Easier  to  regulate  the  amount  of 
light. 

In  large  institutions  acetylene  gas  may  be  used  economically.  The  qual- 
ity of  the  light  is  excellent  and  with  proper  care  the  amount  of  smoke  is 
very  slight. 

There  is  some  danger  of  explosions  if  the  apparatus  is  not  handled  by  a 
careful  person. 

Plumbing. 

Plumbing  in  residence  and  hotel  construction  has  been  perfected  to  such 
a  degree  that  if  the  same  care  is  employed  in  the  installment  of  hygienic 
plumbing  in  hospitals  there  is  no  reason  for  change  or  improvement,  with 
the  exception  that  special  facilities  are  required  for  disposing  of  contents  of 


9IO  THE    SURGICAL    HOSPITAL 

bed-pans,  etc.  A  large  slop  sink  and  hopper,  with  a  water  seal  which  will 
at  once  dilute  any  offensive  matter  thrown  into  it,  has  been  constructed  re- 
cently and  is  of  great  value.  It  is  provided  with  syphon  together  with  a 
large  plunger  which  cleanses  the  entire  contrivance  thoroughly  and  at  once. 
Sterilizing  Rooms. 

Sterilizers  for  surgical  dressings,  sheets,  towels,  instruments,  etc.,  are 
so  perfect  as  supplied  by  many  manufacturers  that  it  is  scarcely  necessary 
to  dwell  upon  them.  Sterilizers  for  mattresses  are  not  so  satisfactory  as  yet. 

Floors. 

In  the  halls,  bathrooms,  closets,  kitchens,  operating  and  dressing  rooms, 
some  form  of  flooring  which  is  impermeable  to  moisture,  such  as  tiling  or 
glass,  has  been  generally  adopted  with  great  satisfaction,  as  it  may  be  easily 
kept  clean  and  is  attractive  in  appearance.  The  most  satisfactory  material 
is  known  as  flake  mosaic,  especially  if  this  is  made  in  the  form  of  large 
tiles.  In  the  wards  and  rooms  hardwood  floors  laid  on  the  cement  covering 
which  isolates  the  floor  from  the  lower  story,  seems  preferable.  This  should 
be  covered  by  some  dressing  impermeable  to  moisture  in  order  to  prevent 
septic  materials  from  penetrating  the  pores  of  the  wood.  A  careful  applica- 
tion of  grain  alcohol  shellac  closes  the  pores  quite  effectually. 

The  walls  should  be  covered  with  paint,  which  prevents  the  plaster 
from  becoming  filled  with  germs.  These  walls  may  be  washed  and  thus 
rendered  aseptic  after  the  rooms  have  been  occupied  by  patients  with  sup- 
purating wounds. 

In  the  operating  and  dressing  rooms  walls  covered  with  tile,  marble, 
glazed  brick  or  glass  are  very  attractive,  but  they  are  in  no  way  superior  to 
those  that  have  been  carefully  covered  with  hard  enamel  paint  which  is 
impervious  and  acid  proof. 

HOSPITAL   MANAGEMENT. 

Concerning  the  internal  management  of  hospitals  there  is  much  to  be 
said,  because  at  the  present  time  no  definite  system  has  been  established,  ex- 
cept in  hospitals  under  the  control  of  sisterhoods  that  have  conducted  sim- 
ilar institutions  for  many  years  in  the  past. 

In  other  American  hospitals  the  management,  as  a  rule,  is  the  cause  of 
almost  unceasing  annoyance  to  every  one  connected  with  the  work.  In  time, 
no  doubt,  there  will  be  developed  as  definite  systems  of  management  of  hos- 
pitals as  now  exist  in  other  departments  of  human  activity.  There  are  very 
definite  plans  for  conducting  almost  all  other  enterprises.  One  would  not 
expect  to  manage  a  railroad,  bank,  department  store,  saw-mill  or  any  other 
industry  unless  one  had  a  definite  knowledge  of  a  system  according  to  which 
such  industries  were  commonly  conducted  with  success,  simply  because  it 
would  not  be  possible  to  compete  with  those  who  have  this  knowledge. 

It  is  quite  different  in  the  control  of  hospitals,  because  any  deficit  which 
may  occur  as  the  result  of  incompetent  or  bad  management  can  readily  be 
made  up  by  contributions  from  those  who  are  interested  in  these  institutions 
as  public  charities.  This  is  true  to  so  great  an  extent  that  one  almost  in- 
variably finds  that  the  institutions  which  are  worst  managed  are  at  the  same 
time  most  generously  supported. 

Fortunately  many   of  the   smaller   institutions   have  but   little  outside 


THE    SURGICAL    HOSPITAL  9!  I 

support  and  consequently  their  existence  depends  upon  the  ability  of  those 
in  charge  to  develop  a  reasonable  plan  of  management,  and  this  condition 
must  in  time  result  in  a  recognized  system  which  will  ultimately  become 
generally  adopted. 

For  the  management  of  smaller  hospitals  it  will  be  necessary  to  have 
nurses  educated  in  training  schools  not  only  to  do  scientific  nursing,  but  also 
to  perform  all  the  other  duties  connected  with  the  government  of  hospitals. 

Fortunately  several  training  schools  for  nurses  have  been  organized 
during  the  past  few  years  with  this  end  in  view,  and  a  number  of  the  older 
schools  have  added  new  departments  of  instruction  in  order  to  enable  their 
pupils  to  become  more  broadly  educated,  with  a  view  of  making  them  more 
thoroughly  competent  to  manage  the  great  number  of  new  hospitals  which 
are  springing  up  in  all  parts  of  this  country. 

If  it  is  possible  to  obtain  a  trained  nurse  who  is  familiar  with  the  de- 
tails of  the  -entire  management  of  a  hospital,  it  is  usually  best  for  all  of  the 
smaller  institutions  to  vest  the  entire  management  of  the  institution  in  this 
office,  i.  e.,  the  superintendent  of  nurses. 

In  order  to  be  competent  to  occupy  this  position  properly,  it  will,  how- 
ever, be  necessary  for  the  occupant  not  only  to  be  an  excellent  nurse,  but 
she  must  be  a  good  housekeeper,  a  good  business  woman,  must  know  how 
to  buy  supplies,  how  to  get  on  with  little  by  economizing  in  every  way.  She 
must  know  how  to  select  help  and  how  to  keep  it.  She  must  be  a  good 
teacher  in  order  to  obtain  satisfactory  work  from  the  pupil  nurses.  She 
must  know  how  to  act  promptly  and  quietly  in  case  of  emergencies.  She 
must  do  all  of  this  cheerfully,  lest  she  drive  patients  away  from  the  hospital, 
and  must  consequently  have  an  unlimited  amount  of  good  judgment  and  tact. 

Above  all  things  she  must  be  absolutely  reliable,  and  must  be  looked 
upon  in  that  spirit  by  every  one  connected  with  the  institution. 

One  quality  which  in  the  main  depends  upon  good  judgment  and  tact, 
but  which  is  but  rarely  found  in  persons  at  the  head  of  hospitals,  is  a  willing- 
ness to  do  what  can  be  done  under  existing  circumstances,  although  it  may 
not  quite  approach  one's  ideals,  without  grumbling  over  things  which  are  for 
the  time  being  impossible. 

A  person  who  possesses  this  quality  at  once  becomes  a  leader  instead 
of  a  master  and  will  consequently  accomplish  vastly  more  in  the  end. 

Many  of  the  smaller  hospitals  owe  their  success,  if  not  their  continued 
existence,  in  a  large  measure  to  the  fact  that  they  were  able  to  secure  the 
services  of  such  a  person  for  the  leading  spirit  in  the  management  of  the 
institution. 

There  are  two  items  which  it  is  important  to  bear  in  mind  at  this  point. 

It  is  important  to  plan  the  work  so  that  this  person  has  one  entire  day 
each  week  away  from  the  institution,  and  some  time  during"  each  day  for  rest 
without  disturbance.  One  who  has  all  of  the  most  desirable  qualities  too 
often  has  not  the  wisdom  to  take  the  necessary  rest  to  be  able  to  continue 
this  work  to  the  fullest  extent. 

The  other  point  is  as  regards  the  authority  of  such  a  person.  She  should 
not  be  hampered  in  any  way. 

It  is  here  that  the  harmful  effect  of  meddlesome  committees  of  women's 
auxiliary  boards  so  often  make  it  impossible  to  develop  a  desirable  system. 
In  the  few  hours  that  a  committee,  composed  of  the  most  excellent  ladies  of 
the  village  or  city,  give  to  hospital  matters  each  week  they  can  usually  per- 


912  THE 


SURGICAL      HOSPITAL 


petrate  more  follies  than  can  be  remedied  during  the  remaining  days  by 
those  who  give  their  entire  time  and  thought  to  the  work. 

No  one  who  does  not  practically  give  all  of  his  or  her  time  to  hospital 
work  should  have  anything  to  say  concerning  the  management  of  the  insti- 
tution, aside  from  auditing  the  accounts,  and  this  should  be  done  by  an  ex- 
pert accountant  whose  only  duty  should  consist  in  determining  the  correct- 
ness of  the  items. 

The  board  of  directors  should  be  divided  into  various  committees  to 
which  questions  of  importance  should  be  referred;  but  no  member  of  the 
board  should  in  any  way  interfere  in  the  conduct  of  the  institution  directly, 
because  it  is  not  at  all  likely  that  he  will  be  in  possession  at  any  time  of  suf- 
ficient data  to  make  his  interference  advantageous  to  the  institution.  Such 
interference  would  not  be  tolerated  in  any  other  business  enterprise  and 
still  it  is  only  too  common  in  the  management  of  hospitals. 

It  should  be  thoroughly  understood  that  hospitals  can  be  -managed  on 
precisely  the  same  principles  that  one  applies  to  any  other  successful  business 
enterprise,  and  that  the  same  principles  will  result  in  similar  success.  This 
has  been  demonstrated  in  a  number  of  the  most  useful  hospitals  in  this  coun- 
try, and  only  when  this  desideratum  has  become  generally  accepted  and 
put  into  practice  can  we  expect  the  greatest  possible  amount  of  benefit  to 
come  from  these  institutions. 

All  persons  performing  work  in  the  hospital  should  be  properly  paid 
for  their  services,  otherwise  the  service  is  certain  to  be  very  inefficient  and 
the  institution  will  be  compelled  to  feed  and  house  an  army  of  incompetents 
who  would  not  even  be  able  to  earn  their  board  and  lodging  elsewhere. 

The  above  tenet  will  make  it  proper  to  expect  good  work  from  every 
one  employed,  and  any  one  who  fails  to  do  his  share  of  the  work  may  be 
dismissed  with  justice  to  himself  and  benefit  to  the  hospital. 

Pupil  nurses  receive  their  tuition  in  the  form  of  lectures,  class  work, 
recitations,  laboratory  work  and  bedside  instruction,  which  should  pay  for 
their  services  in  part  or  in  whole.  In  the  larger  hospitals  this  is  also  true  of 
the  members  of  the  resident  medical  and  surgical  staff. 

The  number  of  assistants,  pupil  nurses  and  servants  necessary  depends 
entirely  upon  the  size  of  the  hospital  and  the  character  of  the  work  per- 
formed. 

In  an  institution  of  less  than  thirty  beds  it  will  not  be  necessary  to 
have  a  matron  or  housekeeper.  In  a  larger  hospital  this  will  be  necessary, 
but  this  position  should  be  under  that  of  superintendent  of  nurses.  It  is, 
however,  a  great  advantage  to  the  institution  to  have  a  matron  who  is  also 
a  graduate  of  a  training  school  for  nurses,  because  she  will  be  much  better 
able  to  comprehend  the  demands  upon  her  department. 

The  other  servants,  such  as  cook,  chamber-maids,  laundress,  janitor, 
as  well  as  the  number  of  pupil  nurses,  will  depend  upon  the  number  of  beds. 

There  are  many  other  items  which  might  be  discussed  in  this  connec- 
tion, but  what  has  been  said  above  will  suffice  to  make  clear  the  most  im- 
portant principles  involved  in  the  organization  of  a  hospital. 

Supplies. 

In  purchasing  hospital  furniture  it  is  important  to  combine  utility  and 
durability  with  attractiveness,  at  the  same  time  securing  furniture  which 
can  easily  be  kept  clean. 

For  a  number  of  years  hospital  authorities  have  neglected  to  pay  suf- 


THE     SURGICAL     HOSPITAL  913 

ficient  attention  to  the  element  of  attractiveness  so  that  the  beds,  for  in- 
stance, remind  one  more  of  cots  in  a  penitentiary  than  of  beds  for  the  use 
of  human  beings  who  need  cheerful  surroundings. 

It  is  now  possible  to  secure  attractive  hospital  beds  which  are  strong, 
easily  cared  for  and  easily  kept  clean. 

The  bed  for  surgical  cases  should  be  high  so  that  the  top  of  the  mat- 
tress is  seventy-five  cm.  from  the  floor.  This  makes  the  work  very  much 
easier  for  the  nurses.  The  beds  should  be  so  built  that  either  the  upper  or 
the  lower  end  can  readily  be  elevated.  It  is  important  to  secure  good 
springs  for  the  bed. 

The  other  articles  of  furniture,  like  bedside  tables,  wash  stands,  etc., 
should  all  be  well  made  of  plain  but  artistic  pattern  and  so  built  that  they 
can  readily  be  kept  clean. 

The  utensils  furnished  by  hospital  supply  houses  are  so  convenient  and 
so  well  made  that  it  is  not  necessary  to  describe  them  especially. 

There  should  be  a  sterilizer  on  each  floor  so  that  all  utensils  may  be 
sterilized  regularly  after  they  have  been  used. 


INDEX 


A  ready  freezing  mixture,  73 

A  great  change  in  mortality  in  acute  per- 

forative  appendicitis,  251 
Abbe's    method     of     dilating    esophageal 

stricture,  522 
Abdominal  hysterectomy,  763 

vs.  vaginal  hysterectomy,  778 

wall,  abscess  in  the,  481 

tumors  in  the,  481 

incisions,  224 

wound  in  chronic  recurrent  appendi- 
citis, 232 

Abdomen,  general  surgery  of  the,  223 
Abscess,  alveolar,  140 

following  emphysema  of  chest,  ISO 

in  the  abdominal  wall,  481 

mediastinal,  197 

of  seminal  vesicles,  750 

of  the  brain,  115 

of  the  mastoid  cells,  115 

of  the  liver,  639 

of  the  lung,  193 
Absorbable  suture  material,  91 
Accessible  nerves   in  local   anesthesia,   65 
Acromion  process,  fracture  of  the,  824 
Actinomycosis,  192 

Acute  appendicitis  with   secondary  infec- 
tion of  the  female  pelvic  organs,  285 

cholecystitis,  606 

gangrenous  appendicitis,  278 

intestinal     obstruction     due    to    con- 
stricting bands  of  adhesions,  375 

mechanical    obstruction   of   the   intes- 
tine, 373 

obstruction   clue   to   kinking  of   intes- 
tines,  375 

perforative  appendicitis,  245 

ulcer  of  the  stomach,  532 
Adenoids,  post  nasal,  135,  149 
Adhesions  in  chronic  recurrent  appendici- 
tis 235 


Advantages  of  the  hospital,  57 

Age  incidence  of   tumors   of   the   breast, 

202 

Alcohol  injection  in  facial  neuralgia,  122 
Alexander  operation,  816 
Alveolar  abscess,  140 
Amputations,  869 

of  the  penis,  697 
Anesthesia,  general,  58 

in  empyema  of  the  chest,  184 

nitrous  oxide  gas,  61 

rectal,  73 

regional,  64 

spinal,   66 

Ankle  joint,  resection  of  the,  857 
Ankylosis  of  jaw,  141 
Angioma  of  the  lip,  150 

Wyeth  method  of  treatment  in,  150 
Ano,  fissure  in,  474 

fistula  in,  475 
Antiseptic  conscience,  46 

fluids,  use  of,  43 

measures  in  injuries  to  the  scalp,  95 
Antitoxin  in  infected  scalp  wounds,  97 
Antrum    of     Highmore,    Beck's    bismuth 
paste  in,  133 

empyema  of  the,  132 
Apparatus,  the  Thoma-Zeiss,  34 
Apparent  cause  of  goitre,  155 
Appendicitis — 

acute  gangrenous,  278 

acute  perforative,  245 

chronic  recurrent,  228 

in  children,  305 

in  old  people,  307 

to  reduce  mortality  from,  262 

cardinal  principles  in.  277 
Application  of  sutures,  87 
Applications,   occlusive   and   antiseptic,  92 
Arbuthnot   Lane's   surgical   treatment   for 

constipation,  359 

Artery,  ligation  of  the  middle  meningeal. 
100 


916 


INDEX 


A  typical  condition   in  chronic  recurrent 
appendicitis,  243 

Avenues  of  infection  in  tonsilar  disease. 
147 

Avoid  pus,  46 

infection  from  surrounding  parts,  44 
any  unnecessary  manipulations,  92 

B 

Bartholin's  gland,  cysts  of,  820 

Beck's  bismuth  paste  in  empyema  of  the 

chest,  186 
use  of  in  tuberculous  glands  of  the 

neck,  170 

in  antrum  of  Highmore,  133 
use  of  in  mastoid  disease,  119 
Benzine,  iodine  and,  44 
Best  time  for  operating  in  hare  lip,  125 
Billroth's   method   of   dilating   esophageal 

stricture,  522 
Bladder,  exstrophy  of.  687 

tumors  of  the,  736 
Blood    analysis    in    exophthalmic    goitre, 

157 

loss  of  in  operations,  23 
technique  for  microscopical  examina- 
tion of,  34 
supply,   importance   of   safe-guarding, 

23 

specific  gravity  of  the,  37 
Blood    vessels,    injuries    to    the    walls    of 

during   operations,  87 
repair  of,  88 
Bone   and   joint   disease,   mixed   infection 

in  tuberculosis,  861 
chisel,   choice    of,   in    depressed    frac- 
tures of  the  skull.  105 
Bones,  crushing  injuries  to,  867 
Bowel  surgery,  general  considerations  in, 

328 

Branchial  cysts,  154 
Brain,  abscess  of  the,  115 
tumors  of  the,  111 
tissue,  laceration  of  the,  104 
Breast,  disseminated  lenticulate  carcinoma 

of  the,  216 

epithelioma  of  the-,  217 
sarcoma  of  the,  217 
tuberculosis  of  the,  217 
tumors  of  the,  201 
Bronchi,  foreign  bodies  lodged  in  the,  221 


Brown  operation  in  cleft  palate,  131 
Brushes,  disinfection  of,  48 
Bunion,  877 


Cachexia  due  to  malignant  growths,  24 

Cancer  en  cuirasse,  216 

Carcinoma  of  the  lymphatic  glands  of  the 

neck,  172 

of  the  lower  jaw,  140 
of  the  stomach,  558 
of  the  tongue,  143 
of  the  rectum,  478 
of  the   upper   portion   of  the   rectum, 

364 

of  the  uterus,  778  " 
Calculus  in  the  ureter,  682 
Carbuncle,  842 

Careful  haste  in  operating,  25 
Cathartics  in  abdominal  surgery,  223 
to  be  avoided  in  peritonitis,  30 
the   introduction   of   in   the  treatment 

of  peritonitis,  311 
Catgut  infection,  50 

ligature,  the  best,  84 

tanned,  52 

iodine,  50 

importance  of  safe,  50 

chromicized,  48 

method  of  preparing  and  preserving, 

48 

Castration,  750 

Caution  against  tight  sutures,  89 
Causes  and  incidence  of  intestinal  fistula, 

367 
Causative  influences  in  tuberculous  glands 

of  the  neck,  165 
Cecum,  excision  of  the,  329 
Cerebral   localization,   108 
Cervix,   dysmenorrhea   due   to   atresia  of, 

820 

erosion  of  the,  794 
laceration  of  the,  807 
Characteristics  of  goitre,  156 
Chemical  tests  for  gastric  juice,  3!* 
Chest,  empyema  of   the,   183 

gunshot  and  stab  wounds  of  the,  .194 
surgery  of  the,  183 
tumors  of  the,  197 
Chloroform   followed  by  ether,  59 
Cholecystostomy,  612 


INDEX 


917 


Cholecystectomy,  C31 
Cholecystenterostomy,  635 
Choledochotomy,  632 
Cholecystitis,  acute,  606 

chronic,  607 
Choice  of  bone  chisel  in   fractures  of  the 

skull,  10.5 
Children,   appendicitis    in,   305 

hernia  in,  442 
Chromicized  catgut,  48 
Chronic  cholecystitis,  607 

mastitis,  201 

osteomyelitis,  835 

recurrent  appendicitis,  228 

epistaxis,  138 

pancreatitis,  467 

subdural  hemorrhage,  103 

ulcer  of  the  stomach,  553 
Cigarette  drain,  54 
Clamps,  hemostatic,  28 

heated,  83 

Class   characteristics   in    acute   appendici- 
tis   with    secondary    infection    of 
the  female  pelvic  organs,  285 
Clavicle     fractures    of    the   outer   end  of 

the,  825 

Cleanliness,  universal  required,  57 
Cleft  palate,  127 
Clips,  metal,   90 
Clinical  experience  in  appendicitis,  264 

of  the  surgeon,  17 
Closure  of  bony  defects  in  the  skull,  108 

of   the   abdominal   wound    in   chronic 

recurrent  appendicitis,  236 
Colon,  resection  of  the,  344 
Colostomy,  inguinal,  350 
Complications  of  appendicitis,  307 

of  floating  kidney,  678 

in  excision  of  tonsil,  147 
Common  duct,  stones  in  the,  607 
Combined  vaginal  and  abdominal  hyster- 
ectomy, 791 

Compound  fractures,  826 
Composition   of  Jenner's  stain,  36 
Conclusions  in  acute  perforative  appendi- 
citis, 261 

in  the  treatment  of  peritonitis.  315 

regarding  tubercular  peritonitis.  327 

regarding  series  of  cases  of  appendi- 
citis, 273 
Contracted  narcs,   135 


Constriction  of  the  duodenum  below  the 
entrance  of  the  common  duct,  636 
Confirmatory  testimony  in  acute  perfora- 
tive appendicitis,  261 

Conditions  of  appendix  after  an  acute  at- 
tack of  appendicitis,  265 
Considerations  of  treatment  in  acute  per- 
forative appendicitis,  246 
Council  method,  the,  in   resection  of  the 

small   intestine,  344 
Constipation,    Arbuthnot    Lane's    surgical 

treatment   for,  359 

Conservative     treatment     in     cecal     dis- 
ease, 333 

Conjoint  diagnosis,  value  of,  31 
Confinement     to     be     avoided     in     opera- 
tions, 10 

Constrictor,  the  pneumatic,  27 
Conscience,  antiseptic,  46 
Confirm  necessity  for  gloves,  47 
Continuance  of  the  drainage  in  empyema 

of  the  chest,  185 
Conditions   favoring  chronic  empyema  of 

the  chest,  188 
Cocaine,  63 
Counting  erythrocytes,  35 

leucocytes,  35 

Crushing,   ligatures  preferable  to,  28 
injuries  of  the  neck,  154 
and  applications  of  heat,  83 
injuries  to  bones,  867 

Crushed  wounds,  tincture  of  iodine  in,  44 
Cysts,    papillomata,    myomata   and   sarco- 
mata of  the  esophagus,  504 
branchial,   154 
of  the  neck,  154 
sublingual,  147 
of  Bartholin's  glands,  820 
pancreatic,  469 
Cyst,  thyroglossal,   180. 
Cystic  duct,  obstruction  of  the,  606 
Cvstotomy,  733 


Dangers  of  slowness  in  operating,  26 

of  supervening  tuberculosis  in  em- 
pyema of  chest,  185 

of  even  simple  growths  in  tumors  of 
the  chest,  201 

minimum  in  exophthalmic  goitre,   162 

signals,  60 


9i8 


INDEX 


of  lung  collapse,  193 
Dangerous     custom     in     tumors     of     the 

breast,  202 
Decapsulation  of  the  kidney  for  chronic 

nephritis,  678 

Decompression  operation,  112 
Deflected  septum,  136 
Dentigerous  cysts  of  the  jaw,  139 
Depressed  fractures  of  the  skull,  105 
Details  of  hand  disinfection,  45 

of  surface  preparation,  43 

of  preparation  in  the  private  home,  57 
Diabetic  gangrene,  871 
Diaphragmatic  hernia,  458 
Diagnostic  error  in   appendicitis   in   chil- 
dren, 306 
Diffuse  peritonitis,  309 

dissecting  lipoma  of  the  neck,  180 
Direction  of  light,  56 
Diuretics  in  surgery  of  abdomen,  223 
Diverticula  of  the  esophagus,  523 
Direction     of     infection     in     tuberculous 

glands  of  the  neck,  165 
Disinfection,  details  of  hand,  45 

of  instruments,  48 

of  silk  ligatures,  etc.,  48 

of  dressings,  53 

general,  53 
Disseminated  lenticular  carcinoma  of  the 

breast,  216 

Disease,  Hodgkin's,  171 
Double  hair  lip,  127 
Drainage,   53 

and    non-irrigation    in    empyema    of 
chest,  184 

continuance  of  in  empyema,  185 

of  the  appendix,  265 

tubes,  disinfection  of,  48 
Drain,  cigarette,  54 
Dressings,  disinfection  of,  53 
Dysmenorrhea,  due  to  atresia  of  the  cer- 
vix, 820 


Effect    of    cathartics    in    mechanical    ob- 
struction  of  the  intestines,  314 
Effusion,  pericardial,  218 
Empyema  of  the  chest,  183 

chronic,  188 

excision  of  costal  cartilages,  221 

of  the  antrnm  of  Highmore,  132 

of  the  frontal  sinuses,  133 


Enlargement   of     the     cervical    lymphatic 
glands     complicated     by     leuke- 
mia,  171 
Epithelioma  of  the  lip,  151 

of  the  face,  151 

of  the  breast,  217 
Epistaxis,  137 
Epiphyseal  fractures,  825 
Epididymectomy,  749 
Epilepsy,  trephining  for  cure  of,  105 
Erosion  of  the  cervix,  794 
Esophagus,  cysts,  etc.,  of,  504 

diverticula  of  the,  523 

foreign  bodies  in  the,  505 

idiopathic  dilatation  of,  524 

injuries  of  the,  505 

inflammation  of,  484 

new  growths  of  the,  486 

phlegmon  of  the,  486 

surgery  of  the,  483 

stricture  of  the,  509 

ulcer  of  the,  486 
Exploring  syringe  condemned,  18 
Exophthalmic  goitr°,  158 
Exstrophy  of  the  bladder,  687 
Esophagoscopy,  484 
Esophagostomy,  491 
Esophagotomy,  181,  508 
Esophagitis,  485 
Ether,  chloroform  followed  by,  59 

preference  given  to,  60 
Ethmoid  cells,  infection  of,  134 
Ethyl  chloride.  73 
ExcKon  of  the  costal  cartilages,  221 

of  the  cecum,  329 

of  gastric  ulcer,  556 

of  the  labia  majora,  etc.,  818 

of  the  parotid  gland,  143 

of  the  saphenous  veins,  844 

of  the  supraorbital  nerve,  125 

of  the  tongue,  143 

of  the  tonsils,  147 

of  the  upper  jaw,  142 

of  the  urethra,  818 

of  the   ureter,  682 

Exceptionally      unfavorable      classes       in 
acute  perforative  appendicitis,  256 
Extremities,  surgery  of  the.  823 

septic  infection  of,  837 

crushing  injuries  of  the,  865 

varicose  veins  of  the  lower,  843 
Examination,  special  methods  of,  32 


INDEX 


919 


technique  of  stomach  contents,  38 
External  urethrototny,  739 


Face,  epithelioma  of  the,  151 
Femoral  hernia,  400 
Female  pelvis,  surgery  of  the,  753 
Fell  bellows,  196 

Floating     kidney     complicating     appendi- 
citis, 309 
Fistula,  permanent  ureteral,  685 

in  ano,  475 

vesico-vagihal,  819 

recto-vaginal,  820 

in  empyema  of  chest,  186 

milk,  218 

intestinal,  367 
Fistulse     following    operation      for     cleft 

palate,  132 
Fissure  in  ano,  474 
Foreign  bodies  in  the  esophagus,  505 

in  the  nose,  137 

in  the  bronchi,  221 
Fracture  of  the  nose,  135 

epiphyseal,  825 

of  the  patella,  823 

of  the  clavicle,  825 

of  the  lower  jaw,  138 

of  the  acromion,  824 

of  the  olecranon,  824 
Fractures,  operative  treatment  of  simple. 
826 

ununited,  828 

compound,  826 
Frontal  sinus,  empyema  of  the,   133 


Gall  bladder  and  liver,  surgery  of  the,  601 
Gangrene,  diabetic,  871 

senile,  870 
Gaseous  distension  in  abdominal  surgery, 

227 

Gasserian  ganglion,   removal   of   the,    120 
Gastric  juice,  chemical  tests  for,  39 

lavage   imperative    in    acute    perfora- 
tive  appendicitis,  252 

ulcer,  excision  of,  556 
Gastro-enterostomy,   541 

enterostomy  with  the  McGraw  elastic 

ligature,  557 

Gastroptosis,  599  , 

Gastrostomy,  492 


Gastrotomy,  508 

General  anesthesia,  58  , 

considerations   in  bowel   surgery,  328 
considerations  in  hernia,  376 
surgery  of  the  abdomen,  223 
Genito-urinary  tract,  surgery  of  the,  649 
Gibson   method    in    resection   of   the   col- 
on, 349 

Glycerine-formaline    solution    in    empye- 
ma of  the  chest,  183 
Goitre,  155 

Guides  to  the  appendix  in  chronic  recur- 
rent appendicitis,  232 
Gunshot  and  stab  wounds  of  the  chest,  194 

H 

Hands,  to  overcome  roughness  of,  46 

preparation  of  the,  45 
Hare  lip,   125 
Heart,  wounds  of  the,  220 
Head,  surgery  of  the,  95 
Hernia,  376 

diaphragmatic,  458 

femoral,  400 

inguinal,  388 

in  old  men,  44S 

in  children,  442 

strangulated,  449 

in  children,  446 

umbilical,  410 

ventral,  420 

of  the  linea  alba,  435 
Hemorrhoids,  469 
Hip  joint,  tuberculosis,  855 
Hospital,  the  surgical,  879 

advantages  of,  59 
Hodgkin's  disease,  171 
Horsehair,  disinfection  of,  48 
Hydrocele,  726 
Hydatids  of  the  livir,  641 
Hydrothorax,  197 
Hypospadias,  719 
Hysterectomy,  abdominal,  763 

vs.  vaginal,  778 

vaginal,   778 


Idiopathic  dilatation  of  the  esophagus,  524 
Inflammatory  processes  of  the  esophagus, 

484" 

Infected   scalp  wounds,   96 
Infections  of  the  mammarv  gland,   198 


920 


INDEX 


Infection,  catgut,  50 

of  the  kidney,  653 

of  the  ethmoid  cells,  134 

of  the  umbilicus,  482 
Inguinal  hernia,  388 

colostomy,  350 
Ingrown   toe   nail,  872 
Injuries  of  the  esophagus,  505 

of  the  liver,  G42 

to  the  walls  of  blood  vessels,  87 

of  the  skull,  99 

to  the  trachea,  153 

to  the  scalp,  95 
Instruments,  surgical,  93 

disinfection   of,  48 
Intussusception,  371 
Intubation,   174 

Intestines,    acute    mechanical    obstruction 
of  the,  373 

small,  resection  of,  343 

acute  obstruction  due  to  kinking,  375 
Intestinal  fistula,  367 

obstruction,  due  to  constricting  bands 

of  adhesions,  375 
Iodine  and  benzine,  44 

catgut,  50 

lodoform-glycerinc   injection    of   tubercu- 
lous joints,  862 


Jaw,  ankylosis  of  the,  141 

dentigerous  cysts  of  the,  139 
tumors  of  the,  138 
Jenner's  stain,  composition  of,   36 
Joints,  tuberculosis  of  the,  855 

tuberculous,  iodoform-glycerine  in- 
jections of,  862 

Jonnesco's  description  of  method  of  spin- 
al anesthesia,  67 

K 

Kidney,  complications  of  floating,  678 

cystic,  671 

decapsulation  of  the,  for  chronic 
nephritis,  678 

infection   of   the,  653 

nephorrhaphy  for  the  relief  of  mov- 
able, 672 

plastic  operations  on  the  pelvis  of  the 
677. 

resection   of   the,   681 


Laceration  of  brain  tissue,  104 

of  the  cervix  uteri,  807 

of  the  perineum,  800 
Laryngectomy,   179 
Laryngotomy,  178 
Later  appendectomy  in   acute   perforative 

appendicitis,  261 
Laxatives  before  operations,  21 
Lip,  tumors  of  the,  150 

angioma  of  the,  150 

epithelioma  of  the,  151 
Ligature  method  in  hemorrhoids,  473 

catgut  the  best,  84 

material,   83 

Ligatures    in    chronic    recurrent    appendi- 
citis, 235 
Ligation  of  the  middle  meningeal  artery, 

100 

Lignous  infiltration  of  the  neck,  172 
Linea  alba,  hernia  of  the,  435 
Liver,  abscess  of  the,  639 

hydatids  of  the,  641 

injuries  of  the,  642 

wounds  of  the,  642 
Lower  jaw,  carcinoma  of  the,   140 

fractures  of  the,  138 

osteomyelitis  of  the,   140 

sarcoma  of  the,  140 
Local  anesthesia,  62 
Localization,  cerebral,  108 

of  the  disease  in  appendicitis,  266 
Lung,  abscess  of  the,  193 

collapse,  193 
Lympho-sarcoma  of  the  neck,  171 

M 

Malignant  growths  of  the  thyroid  gland, 

164 

rules  ignored   in,  76 
Mammary  gland,  infections  of  the,  198 
Management,   hospital,  910 
Manipulations,  avoid  any  unnecessary,  92 
Mastitis,  chronic,  201 
Mastoid  cells,  abscess  of  the,  115 

operation  in  chronic  cases,  119 
Material,  ligature,  84 
McGraw  elastic  ligature,  gastro-enterost- 

omy  and  entero-cnterostomy  with 

the,   557 
Meal,  test,  38 
Mediastinal  abscess,  197 


INDEX 


921 


Medical   vs.   surgical   treatment   in   tuber- 
cular peritonitis,  319 
Metal  clips,  90 
Method,  Hammerschlag's,  37 

of  hemostasis   in   excision   of   tonsils, 

148 

of  holding  patient  in  excision  of  ton- 
sils, 149 
of    preparing  and   preserving   catgut, 

48 
of    production    of    infections    of    the 

mammary  gland,  198 
of    prevention    of    infections    of    the 

mammary  gland,  198 
of  spinal  anesthesia,  67 
Milk  fistula,  218 
Mixture,  a  ready  freezing,  73 
Mixed  infection  in  tuberculous  bone  and 

joint  disease,  861 
Mobilizing   the    chest   wall    for    relief    of 

pericardial  adhesions,  218 
Mode  of  action  of  cathartics  in  peritoni- 
tis, 312 

Modern  treatment  and   recurrence  of  tu- 
mors of  the  scalp,  97 
Morphin  and  atropin  hyperdermically,  61 

and  scopolamin  in  anesthesia,  73 
Myomectomy,  771 

N 

Xasal  polypi,  135 
Nares,  contracted,  135 
Nature's  protective  influences  in  appendi- 
citis, 267 
Neck,  surgery  of  the,  153 

crushing  injuries  of  the.  154 

cysts  of  the,  159 

carcinoma  of  the,  172 

diffuse  dissecting  lipoma  of  the,   180 

lignous   infiltration   of  the,   172 

lympho-sarcoma  of  the,  171 

septic    infection    of    the    deep    tissues 

of,  172 

Nephrectomy,  665 
Nephrorrhaphy  for  the  relief  of  movable 

kidney,  672 
Nerve  sutures,  847 

resection  of  inferior  dental.  124 

infra-orbital,  124 

supra-orbital,  125 

New  growths  of  the  esophagus,  486 
Nitrous  oxide  gas  anesthesia,  61 


Non-absorbable  suture  material,  90 

malignant     conditions,    vaginal     hys- 
terectomy for,  792 
traumatic  infection  of  the  scalp,  99 

Nose,  fracture  of  the,  135 
foreign  bodies  in  the,  137 

O 

Obstruction   of  the  cystic  duct.  606 
Occlusive   and   antiseptic   applications,    92 
Old  men,  hernia  in,  448 
Old  people,  appendicitis  in,  307 
Olecranon,  fracture  of  the,  824 
Operating  room,  temperature  of,  29 

tables,  warm,  29 
Operation,  decompression,  112 
for   splenectomy,  460 
for  wandering  spleen,  463 
mastoid  in  chronic  cases,  119 
preparation  of  the  patient  for,  30 
the  field  of,  43 

Operative  precautions  and  technique   in 
removal   of   the   Gasserian   gang- 
lion,  120 
principles    in    tumors    of    the    breast, 

215 

treatment  of  simple  fractures,  826 
Osmic  acid  injections  in  resection  of  por- 
tions of  the  facial  nerve  for  the 
relief  of  neuralgia,  123 
Osteomyelitis,   chronic,   835 
of  the   lower  jaw,   140 
Ovarian  tumors,  753 
Ovaries,  transplantation  of,  777 


Pancreatic  cysts,  469 
Pancreatitis,  464 

Paraffin,  ligature  material  boiled  in,  52 
Parotid  gland,  excision  of  the,  143 
Patella,  fracture  of  the,  823 
Pathological  appearances  of  the  appendix 
in  chronic  recurrent  appendicitis, 
243 

Penis,  amputation  of  the,  697 
Pericardial  adhesions.  218 
effusion,  218 
suppuration,  219 

Perineum,  laceration  of  the.  809 
Peristaltic  motion  of  the   small   intestines 
in  acute  perforative   appendicitis, 
250 


922 


INDEX 


Permanent  ureteral  fistula,  686 

Pertinent    conclusions    regarding    hernia 
in  children,  448 

Peritonitis,  309 

cathartics  to  be  avoided  in,  30 

Phlegmon  of  the  esophagus,  486 

Physical  signs  of  abscess  of  the  lung,  193 
of  tumors  of  the  breast,  201 

Phosphorus  poisoning,  141 

Plastic   operations   on    the   pelvis    of    the 
kidney,  677 

Pneumothorax,  195 

Poisoning,  phosphorus,  141 

Polypi,  nasal,  135 

Positive  sign  of  actinomycosis,  192 

Post-nasal  adenoids,  135 

Prolapse  of  the  rectum,  477 
of  the  uterus,  793 

Prolonged     preparatory     treatment     con- 
demned, 42 

Properly  conducted   ether  anesthesia  has 
all  advantages,  62 

Prostatectomy,  742 

Prostatotomy,  748 

Preference  given  to  ether,  60 

Pregnancy  complicating  appendicitis,   309 

Pre-operation  milk  diet   favors  hemosta- 
sis,  28 

Preparatory  treatment   in   cecal   excision, 

334 

prolonged  condemned,  42 
in  surgery  of  the  abdomen,  223 

Preparation  of  the  patient  for  operation, 
30 

Prevention   and   inhibition   of   peritonitis, 
310 

Private   home,    details    of   preparation    in 
the,  57 

Prognosis   of   chronic   recurrent   appendi- 
citis, 231 

Pyelotomy,  681 

Pylorus,  resection  of  the,  578 

Pyosalpinx,  772 

R 

Radiscopy,  484 

Radical  operation  in  hemorrhoids,  474 

Ranula,   144 

Rectum,  carcinoma  of  the,  478 

of  the  upper  part  of,  -'564 

prolapse  of  the.  477 

the  combined  abdominal  and  perineal 


method    of    removing    carcinoma 
of,   480 

Rectal  anesthesia,  73 
Recto-vaginal  fistula,  820 
Regional  anesthesia,  64 
Reiteration  of  cardinal  principles  of  treat- 
ment of  appendicitis,  277 
Removal  of   Gasserian  ganglion,   120 
tonsils  and  adenoids  of  neck,  168 
Removing  the  appendix  in  chronic  recur- 
rent appendicitis,  235 
Resection  of  the  ankle  joint,  857 
kidney,  681 

strictured  urethra,  741 
facial  nerve,  122 
inferior  dental  nerve,  124 
infra  orbital  nerve,  124 
small  intestine,  343 
colon,  344 

Resume   of    cases    of    tubercular   periton- 
itis, 321 

Repair  of  blood  vessels,  88 
Return   to   diet   in   acute   perforative   ap- 
pendicitis, 256 
Review  of  an  extensive  series  of  cases  of 

appendicitis,  268 
Ribs,  tuberculosis  of  the,  192 
Rules  governing  sutures  in  cecal  excision, 

340 
Rupture  of  the  urethra,  740 

S 

Sacro-iliac  joint,  tuberculosis  of  the,  860 
Saddle-nose,  136 
Sarcoma  of  the  scalp,  98 

of  the  lower  jaw,  140 

of  the  breast,  217 
Scalp,  injuries  to  the,  95 

sebaceous  cysts  of  the,  97 

sarcoma  of,  98 

tuberculosis  of  the,  99 

tumors  of  the,  97 

wounds  of,  96 

Scopolamin    and   morphine   anesthesia,   73 
Schleich's  infiltration  method,  64 
Section  of  the  ureter,  685 
Sebaceous  cysts  of  the  scalp,  97 
Seminal  vesicles,  abscess   of  the,  750 
Senile  gangrene,  136 
Septum,  deflected,  136 
Septic  infection   of  deep  tissues  of  neck, 
172 


INDEX 


923 


of  the  extremities,  837 
Skull,  closure  of  bony  defects  in,  108 

depressed  fractures  of  the,  105 

primary  tumors  of  the,  107 

tuberculosis  of  the,  107 
Skin  grafting,  846 
Small  intestine,  resection  of,  343 
Spasmodic  torticollis,  173 
Spinal  anesthesia,  66 
Special  training  and  experience  in  tumors 

of  the  brain,  111 

Spontaneous  cure  of  intestinal  fistula,  367 
Splenectomy,  459 
Spleen,  wandering,  463 
Splitting  of  the  uterus,  764 
Sternum,  tuberculosis  of  the,  197 
Starvation  plan  of   great   value  in   acute 

perforative  appendicitis,  251 
Stovain  and  strychnine,  67 
Stomach,  acute  ulcer  of  the,  532 

surgery  of  the,  529 

carcinoma  of  the,  558 

chronic  ulcer  of  the,  533 
Strangulated  hernia,  449 

in  children,  446 

complicating  appendicitis,  308 
Stricture  of  the  esophagus,  509 
Stones  in  the  common  duct,  607 
Surgery  of  the  abdomen,  223 

chest,  183 

extremities,  823 

esophagus,  483 

female  pelvis,  753 

genito-urinary  tract,  649 

gall  bladder  and  liver,  601 

head,  95 

neck,  153 

stomach,  529 
Surgical  instruments,  93 

methods,  theory  vs.  practice  in,  55 

treatment  of  acute  pancreatitis,  468 

treatment  of  chronic  pancreatitis,  467 
Sutures,  nerve,  847 

tendon,  851 

in  cleft  palate,  131 

rules  governing,  in  cecal  excision,  340 
Sublingual  cysts,  147 


Tanned  catgut,  52 

Technique  of  lavage  in  acute  perforative 
appendicitis,  255 


Tendon  sutures,  851 

transplantation,  852 
Tests  for  tuberculosis,  32 
Testicle,  tumors  of  the,  751 
Theory  vs.   practice   in   surgical   methods, 

55 
The  operating  room,  56 

introduction  of  cathartics  in  the  treat- 
ment of  peritonitis,  311 
Connell  method  of  resection  of  bow- 
els, 344 
question    of    immediate    operation    in 

cecal  disease,  330 
Fowler  position  in  acute  perforative 

appendicitis,  256 
determining    condition    of    immediate 

operation  in  appendicitis,  266 
Murphy  button,  339 
effect  of  the  introduction  of  any  kind 
of    food    or    cathartic    into    the 
stomach  in  acute  perforative  ap- 
pendicitis, 250 

suture  method  in  cecal  excision,  339 
Mayo   technique   in   umbilical   hernia, 

414 

combined     abdominal     and     perinea! 
method    of    removing    carcinoma 
of  the  rectum,  480 
surgical  hospital,  879 
treatment  of  crushing  injuries  of  ex- 
tremities, 865 
Thrombo-phlebitis,  309 
Thyroid  gland,  malignant  growths  of,  164 
Thyroglossal   cyst,   180 
Tincture  of  iodine  in  crushed  wounds,  44 
Time  limit  of  local  infection   in  appendi- 
citis, 266 

To    reduce    the    mortality    from    appendi- 
citis, 262 

Toe  nail,  ingrown,  872 
Toxic  esophagitis,  485 
Tongue,  excision  of  the,  143 

carcinoma  of  the,  143 
Tonsils,  excision  of,   147 
Tonsilar  disease,  avenues  of  infection,  147 
Torticollis,   172 

spasmodic,  173 
Trachea,  injury  to  the,   153 
Tracheotomy,  173 
Transplantation  of  ovaries,   777 
Traumatism  in  abdominal  surgery,  227 
Trusses,  use  of  in  hernia  in  children,  447 


924 


INDEX 


Trephining  for  the   cure  of  epilepsy,   105 
Treatment  of  acute  gangrenous  appendi- 
citis, 297 

of  tubercular  peritonitis,  318 

of  chronic  pancreatitis,  467 
Tuberculin,  32 
Tubercular  peritonitis,  317 
Tuberculous  bone  and  joint  disease,  mixed 

infection  in,  861 
Tuberculosis,  hip  joint,  855 

tests  for,  32 

of  the  breast,  217 

of  the  sternum,  197 

of  the  ribs,   192 

of  the  skull,  107 

of  the  scalp,  99 

of  the  joints,  855 

of  the  sacro-iliac  joint,  860 

of    the    shoulder,     elbow     and    other 
large  joints,  860 

of  the  glands  of  the  neck,  165 
Tumors  of  the  breast,  201 

of  the  bladder,  736 

of  the  abdominal  wall,  481 

of  the  jaw,  138 

of  the  skull,  106 

of  the  lip,   150 

of  the  testicle,  751 

of  the  chest,  197 

of  the  brain,  111 

of  the  scalp,  97 

ovarian,  753 

diagnostic    palpation    of    condemned. 
18 

section  of  condemned,  17 
Typhoid    fever    complicating   appendicitis, 

308 

Typical   history   of   acute   perforative   ap- 
pendicitis, 245 

instance  of  chronic  recurrent  appendi- 
citis, 228 

U 
Ulcer  of  the  esophagus,  486 


stomach,  556 
Ulcers,  varicose,  845 
Umbilicus,  infection   of  the,  482 
Umbilical  hernia,  410 
Uniting  of  vas  deferens,  750 
Ununited  fractures,  828 
Upper  jaw,  excision  of,  142 
Urethrotomy,  737 
Urethra,  excision  of  the  female,  818 

rupture  of  the,  740 

resection  of  the  strictured,  741 
Ureter,  excision  of  the,  682 

calculus  in  the,  682 

section  of  the,  685 
Uterus,  carcinoma  of  the,  778 

prolapse  of  the,  793 

splitting  of  the,  764 


Vaginal  and  abdominal  hysterectomy,  791 

hysterectomy,   778 

for  non-malignant  conditions,  792 
Varicocele,  722 
Varicose  ulcers,  845 

veins  of  lower  extremities,  843 
Vas  deferens,  uniting  of,  750 
Vasectomy,  741 

Veins,  excision  of  saphenic,  844 
Ventral  hernia,  420 
Vesicocele.  817 
Vesco-vaginal  fistula,  819 
Volvulus,  373 

W 

Wandering  spleen,  463 

Wounds,  suturing  of  deep,  89 
superficial,  89 

after-treatment  of   aseptic,   91 
of   clean  becoming  infected,  93 
disinfection   of   everything  coming  in 

contact  with,  53 
of  the  heart,  220 
liver,  642 

Wyeth  method  in  angionia  of  lip,  150 


Date  Due 


001384177  o 


Ochsner,  Albert  J 

A  nev  clinical  surgery. 


WO  100 
0  I6n 
1910 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


